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David  Wrenn  Krunbhaar, 
Peter  H.  Krunbhaar  and 
Peter  D.  Krur.ibhaar 


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1 

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en  bas,  en  prenant  le  nombre  d 'images 
necessaire.   Les  diagrammes  suivants  illustrent  la 
methode. 


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EXPLANATION  OF  PLATE  I. 

The  drawings  were  made  with  the  camera  lucida  and  with  a  Spencer 
microscope,  objective,  4  mm.,  ocular,  8.  ,        »      .     j 

Figs  1  2,  and  3  represent  lesions  in  a  dog  that  was  splenectom.zed 
on  March  n,  1912,  received  hemolytic  serum  on  March  14,  and  died 
on  March  15.    The  actual  lapse  of  time  was  about  thirty-six  hours. 

Fio  1  Peripheral  sinus  of  a  mesenteric  lymph  node  contammg 
large  numbers  of  endothelial  cells  filled  with  red  blood  corpuscles  and 
occasionally  also  polymorphonuclear  leucocytes. 

F.o    2     Similar  cells  in  a  central  sinus  of  the  same  lymph  node. 

Fio.  3.    A  section  of  liver  with  two  Kupfer  cells  containing  red 

blood  corpuscles.  .      •  _j 

F.o.  4.  Similar  to  figure  3,  but  from  a  dog  that  was  splenectom.zed 
on  July  19,  1911.  received  hemclytic  serum  on  March  8,  1912,  and  died 
after  forty-eight  hours. 


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THE 

SPLEEN  AND  ANAEMIA 

EXPERIMENTAL  AND  CLINICAL  STUDIES 


BY 

RICHARD  MILLS  PEARCE,  M.D.,  Sc.D. 

PHOrESSOR    OF  OESEARCH   MEDICINE 
WITH  THE  ASSISTANCE  OF 

EDWARD  BELL  KRUMBH.\AR,  M.D.,  Ph.D. 

AI8IST1NT  rROrSMOR  Or  RESEARCH  MEDICinS 

AMD 

CHARLES  HARRISON  FRAZIER,  M.D.,  Sc.D. 

PBOFEMOR  OF  CLINICAL  BUBOEBT,    DNrVEBaiTT  0»  PENHSTLTANIA 


16  1LLUSTRATW.\S.  COLOR  AND  BLACK  AND  WHITE. 


PHILADELPHIA  AND  LONDON 
J.  B.  LIPPINCOTT  COMPANY 


OPTBIQHT,    I<JlR,    BT  /,    B.    LIPPINCOTT  CnuPlHT 


Z-^  c^\^ 


Electrotyped  and  Prinlcd  by  J   li.  Lippincnti  Company 
The  Washinginn  Square  Pns.i,  I'liiladelphia.  {'.  S.  A. 


I 


^^^m^. 


TO  THE  LIBERAL  AND  FAE-SIGHTED  BENEFACTOR 
WHO  ESTABUSHED.  UNDER  THE  CLOAK  OF  ANO- 
NYMITY. THE  JOHN  HERR  ML'SSER  DEPARTMENT  OF 
RESEARCH  MEDICINE  IN  THE  UNIVERSITY  OF  PENN- 
SIXVANIA.  THIS   BOOK  IS  GEATEFUUY   DEDICATED 


I 


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I 


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Hm^'^imM:.  . 


PREFACE 

Ik  this  volume  splenectomy  is  considered,  first,  as  a 
means  of  studying  experimentally  in  animals  the  relation 
of  the  spleen  to  blood  destruction  and  regeneration  and, 
second,  as  a  therapeutic  procedure  in  the  treatment  of  dis- 
eases of  man  accompanied  by  anaemia.  No  attempt  is  made 
to  discuss  injuries,  infections  and  tumors  of  the  spleen,  or, 
except  incidentally,  the  problems— leucocytosis  and  leu- 
ca-mia— of  the  white  blood-cells.  The  emphasis  is  on  the 
side  of  the  red  blood-cell  and  the  relation  of  the  spleen  to 
the  quantitative  and  (pialitative  changes  which  the  red  cell 
may  undergo. 

The  chapters  on  experimental  and  metabolic  observa- 
tions ar  based  on  some  twenty  odd  studies  carried  out 
during  the  past  five  years  in  li.e  John  Herr  Musser  Depart- 
ment of  Research  Medicine  of  the  University  of  Penn- 
sylvania, and  reported  from  time  to  time  in  medical  period- 
icals, under  the  general  title  of  "  The  Relation  of  the  Spleen 
to  Blood  Destruction  and  Regeneration  and  to  Hjemolytic 
Jaundice."  These  various  papers  have  been  rearranged 
and  largely  rewritten  and  brought  into  relation  with  the 
general  literature  so  as  to  offer  a  consecutive  comprehensive 
presentation  of  the  general  experimental  problem. 

Such  experimental  studies  are  obviously  of  importance 
in  connection  Mith  the  diseases  of  man  characterized  by 
splenomegaly,  with  ana?niia  or  jaundice,  or  both,  and  in 
connection  with  which  splenectomy,  as  a  therapeutic  pro- 
cedure, has  recently  been  so  widely  tried.  Clinical  studies 
of  the  splenomegalies  and  of  the  results  of  splenectomy  in 
man  are  therefore  presented  by  Dr.  Krumbhaar.  These 
chapters  bring  into  one  volume  for  the  first  time  the  modern 


\V  ■:■*,* 


v^-  ^..ii^^v^T^^m}^^^^^^^ 


VI 


PREFACE 


views  concerning  the  classification,  diagnosis  and  treatment 
of  the  non-infectious  splenomegalies  characterized  by  blood 
destruction.  The  final  section  by  Dr.  Frazier  gives  details 
of  the  technic  of  the  operation  of  splenectomy  in  man.  This 
has  been  included,  partly  to  complete  our  presentation,  but 
chiefly  to  bring  out  new  points  concerning  the  operation 
which  have  been  gained  as  the  result  of  its  widely  extended 
use  during  the  last  few^  years. 

Acknowledgments  are  due,  and  are  gratefully  made,  to 
those  assistants,— J.H.Austin,  M.D. ;  Harry  Dubin,  P'i.D. ; 
A.  B.  p:isenbrey.  M.D.;  Samuel  Goldschmidt,  Ph.D.;' 
H.  T.  Karsner,  M.D.;  E.  B.  Krumbhaar,  M.D.;  J.  H. 
Musser,  Jr.,  M.D.;  M.  M.  Peet,  M.D.,  and  O.  H.  Perry 
Pepper,  M.D.,— who  assisted  in  the  experimental  work  and 
thus  made  possible  the  many  detailed  studies,  and  likewise 
to  the  Board  of  Scientific  Directors  of  the  Rockefeller  In- 
stitute for  Medical  Research,  who  by  grants  of  money  from 
time  to  time  furthered  the  distinctly  laboratory  studies.  To 
the  editors  of  the  Journal  of  Experimental  Medicine, 
Archives  of  Internal  Medicine,  American  Journal  of  the 
Medical  Sciences,  The  Journal  of  the  American  Medical 
Association  and  the  AVro  York  Medical  Journal,  we  „re 
also  indebted  for  the  privilege  of  reproducing  in  the  present 
form  material  originally  appearing  in  their  journals. 


Tlie  material  presented  under  the  headings  of  experi- 
mental and  metal)olic  studies  constitutes  the  substance  of  the 
Cartwright  Lectures  delivered  in  Aew  York  on  October  '2i 
and  25,  1910,  under  the  auspices  of  the  Association  of  the 
Alumni  of  the  College  of  Physicians  and  Surgeons  of 
Columbia  University. 

September,  1017.  T,,,,     4 

1  HE  ArTTIORS. 


I 
I 


H 


CONTENTS 

PART  I. 

Experimental  Studies  by  R.  M.  Peabce. 

CHAPTER 

I.  The  History  oi  Extirpation  of  the  Spleen  *'''''? 

I'.  The  Effect  of  Splenectomy  in  the  Dog  n 

11^  V'a  ^"^f^  ^-^  ^^'  ^"^'•^^^d  Resistance' of 
the  Red  Blood-cells.  (3)  The  Decreased  Tendency  of 
Hsemolytic  Agents  to  Cause  Ha^mogiobinuria  and 
Jaundice. 

III.  Concerning    the    Supposed    Regulatory  Influence 
of  the    Spleen    in    Blood    Destruction   and 

Regeneration 

A.  In  Relation  to  the  Decreased  Tendencv"  to 
Haemoglobinuna  and  Jaundice:  (1)  The  Refation 
of  Spleen  to  the  Liver  and  the  Formation  of  Bile 
from  Hseinoglobin,  (2)  The  Influence  of  the  Course 
of  the  Blood  to  the  Liver.  (3)  The  Influence  of 
AmKima    (4)  Influence  of  the  Increased  Resistance 

ll-  p'  5^f  xf '"'',  ^^^  ^  ^P'"'^'^  E'^t'-^t^  H^mcv 
lytic?    (6)  Ha^molytic  Influence  of  Fatty  Acids  and 
l.ipoids  in  Hemolysis. 
TV.  Concerning  the  Supposed  Regulwory  Inixuence  of 
THE   Splv.en   in   Blood   Destruction   and   Re- 
generation   

B.  In  Relation  to  Anaemia:   (1)  A  Comparison  of  the 
Artenal  and  Venous  Bl<x,d  of  the  Spleen,  (i)  Influence 
ot  bplenic  Extract  upon  Blood  Formation,  (3)  Influ- 
ence of  Feeding  Spleen  to  Splenectomized  Dogs    (4) 
The  Repair  of  an  A.tiflcially  Produced  Ana-mia  in 
Sp  enectom.zed  Animals.    (5)  The  Influence  of  the 
spleen  upon  Iron  Metabolism. 
V.  Control     Experiments:      The     Diversion    of    the 
Splenic  Bi^ood  from  the  Liver  Without  Re- 
moval OF  THE  Sl'LKf^N 


87 


121 


vu 


viii  CONTENTS 

(1)  By  Ligation  of  the  Splenic  Vein,  (i)  By  Trans- 
plantation of  the  Splenic  Vein  into  the  Vena  Ca\a, 
(3)  By  Eck  Fistula. 
VT.  TuE  Changes  in  the  Bone-makrow  Ajter  Splenectomy  140 
(1)  Discussion    of    the    Literature,    ('2)    Histological 
Studies  of  the  Dog's  Normal  Alarrow,   (3)  Changes 
After  Splenectomy. 
VIL  The  Changes  in  the  Liver  and  Lymph-nodes  After 

Splenectomy 164 

Discussion  of  the  Literature.     Changes  in  Lymph- 
nodes.      Phagocytosis   of   Red   Cells   by   Endothelial 
Cells   of   Lymph-nodes   and   Liver.      Micnx'hemical 
Test  for  Iron  in  Lymph-nodes  and  Liver. 
VIIL  Met.vbolism  Studied  on  the  Dog  Before  and  After 

Splenectomy 181 

IX.  General  Summary  of  Experimental  Studies 195 

X.  Metabolism    Studies    on    Man    Before    and    .\fter 

Splenectomy io% 

PART  II 

Clinical  Observation^  by  E.  B.  KRUMBHA.^R 
XI.  Classification  and   Analysis   of   Types   of   Spleno- 
megaly Accompanied  by  An.eml\ 241 

Splenic  Anaemia,  Gaucher's  Disease.  Banti's  Disease, 
Von    Jaksch's    Disease,    .Vcejuired    and    Congenital 
Hemolytic  Jaundice,  Pernicious  An;emia. 
XII.  Methods  of  Value  in  the  Diagnosis  and  Prognosis 

of  Splenic  Disease i269 

XIII.  Treatment  of  Splenic  Diseases  by  Methods  (>riiEi{ 

than  Splenectomy -201 

XIV.  Tre-vtment:    Value  of  Splenectomy  as  a  Theiiapeutic 

Prckedurr <i9g 

PART  III 
Surgical  Observations  p.y  Charles  II.  Frazif.h 
XV.  The  Surgical  Treatment  ok  Lesions  of  the  Spleen  333 

(1)  Preparation    of     the    Patient    for    Splenectomy 

(2)  The  Operation   iind    (3)  The   After-care   of  the 
Patient. 

Bibliography 3.^)9 


•!»  -I  r-- 


ILLUSTRATIONS 

COLOR  PLATES 

^^^"^^  OPPOSITE   PAGE 

I.  Lymph-nodes  and  Liver  of  Splenectomized  Dogs  Receiv- 
ing Ilremolytic  Serum  and  Showing  Phagocytic  Cells 

Containing  Red  Blood-corpuscles Frontispiece 

II.  Histology  of  Gaucher's  Disease.     Alveolar  Arrangement 

of  Large  Vehicular  Cells  with  Small  Concentric  Nuclei  ii5 

III.  Spleen  of  Banti's  Disease 24g 

IV.  Histology  of  Spleen  of  Early  Banti's  Disease 250 

V.  Histoiogj-  of  Spleen  of  Late  Banti's  Diseiise 252 

M.  Histologj'  of  Spleen  of  Congenital  Haemolytic  Icterus.    .  252 

VII.  Spleen  of  Pernicious  iVna>mia 265 

VIII.  Test  for  Resistance  of  Erythrocytes.    Salt  Solution  fNace) 

Varying  in  Strength  from  0.3  to  05  Per  Cent 267 

IX.  Reticulated  Red  Blood-cells.    From  a  Case  of  Hemolytic 

Jaundice g^^g 

X.  The  Relationsiiip  of  the  Tail  of  the  Pancreas  to  the 

Posterior  Aspect  of  the  Pedicle 346 

XL  The  Peritoneal  Prolongation  Between  the  Spleen  and  the 
Splenic  Fle.xure  of  the  Colon,  Which  Must  be  Divided 
Before  the  Organ  Can  be  Completely  Mobilized   ...   347 
XII.  Left-side  Bevan  Incision  for  Splenectomy 350 

XIII.  First  Step  in  the  Mobilization  of  the  Spleen 352 

XIV.  To  Control  Bleeding  After  Mobilization  of  the  Spleen  a 

Large  Tampon  of  Gauze,  Wrung  out  in  Hot  Water, 

is  Introduced  into  the  Left  Hypochondrium 352 

XV.  Fractional  Ligation  After  Isolation  of  the  Vessels  of  the 
Pedicle  by  Blunt  Removal  of  Fat  and  Connective 

T's'^ue 35S 

XVI.  The  Double-clamp  Method  of  Dealing  with  the  Pedicles  35S 

ix 


*  ILLUSTRATIONS 

TEXT  CUTS 

1.  Composite  Cui^-e  of  the  Red  Blood-ceU  Count  of  Seven  Dogs 

After  Splenectomy ,„ 

2.  Composite  Curve  of  the  Hemoglobin  Estimation  of  Seven 

Dogs  After  Splenectomy j^ 

3.  Composite  Curve  of  the  Leucocyte  Counts  of  Five  Dogs  After 

Splenectomy .„ 


mi^^smi^msm^jm^ma^mmMs^^^^^^ammB^ 


PARTI 

EXPERLAIENTAL  STUDIES  BY  R.  M.  PEARCE 


."?£-  ■^i^-'>:s'- 


.f:;^>y/V*-  "-. 


'-fmmm^fm^W^'^:  :''rmm?^'''-''^^m^ 


THE   SPLEEN   AND  ANEMIA 

CHAPTER  I 
THE  HISTORY  OF  EXTIRPATION  OF  THE  SPLEEN 

The  statement  is  frequently  seen  that  the  ancients 
practised  removal  of  the  spleen  in  the  belief  that  it 
improved  the  wind  of  runners.  It  is  also  stated  in  the 
older  literature  that  the  swift  giraffe  is  spleenless,  an 
erroneous  supposition  that  may  have  had  something  to  do 
with  the  views  of  the  ancients  concerning  the  spleen  and 
the  speed  of  runners.  Aristotle  "  assumed  that  the  spleen 
is  not  necessary  for  the  maintenance  of  existence,  and 
Erasistratus  insisted  that  it  is  of  no  use  whatever.  Galen 
more  conservatively  considered  it  an  organ  full  of  mys- 
tery (Mysterii  pleni  organon)  and  that  it  probably 
removed  the  melancholy  of  the  blood  going  from  the  liver 
to  the  stomach.  The  iirst  positive  statement  as  to  its 
extirpation  (not  excision)  is  made  in  Pliny's^"  Natural 
History.  An  old  English «"  translation  runs  as  follows: 
"  This  member  (the  spleen)  hath  a  propriete  by  itself e 
sometimes,  to  hinder  a  man's  running;  whereupon  pro- 
fessed rmmers  in  the  race  that  bee  troubled  with  the  splene, 
have  a  devise  to  burne  and  waste  it  with  a  hot  yron.  And 
no  marveile;  for  why?  They  say  that  the  snlene  may  be 
taken  out  of  the  body  by  way  of  incision,  and  yet  the  crea- 
ture live  neverthelesse;  but  if  it  be  man  or  woman  that  is 
thus  cut  for  the  splene,  he  or  she  looseth  their  laughter  by 
the  means.  For  sure  it  is  that  intemperate  laughers  have 
always  great  splenes."    In  connection  with  the  last  state- 

3 


^ft      ^.--iPr-cyy''^-- 

■B^ 

*  THE  SPLEEN  AND  AN.EMIA 

ment  it  is  interesting  that  the  modern  German  word  for 
hypochondriasis  is  "  Milzsncht."  Phny  is  said  to  have  per- 
formed experiments  involving  the  removal  of  the  spleen 
from  dogs,  hut  this  is  probably  merely  an  incorrect  quota- 
tio.i  of  the  foregoing.  The  belief  that  splenectomy  im- 
P'-oved  the  wind  of  runners  was  not  lost  sight  of  in  the 
nmldle  ages,  as  is  shown  by  the  couplet  quoted  by  Brog- 
sitter      from  Murer's  Belagerung  von  Babylon: 

"Ich  han  mir  Ion  diss  milz  schnydcn, 
Dass  ich  mag  hinfvn  wcgt  urul  veer." 

^^  He  also  quotes  Paracelsus,  who  considered  the  spleen 
des  Le.l,ers  und  Lebens  Unkraut,"  and  advised  phv- 
s.cans  to  excse  it  whenever  possible.  Van  Ilelmont,  /m 
the  other  hand,  attributed  to  it  important  and  even  vi.al 
tunctions. 

The  first  authentic  experimental  splenectomv  in  the 
cog  was  performed  l)y  Zambeccari  -^=  in  ir.80,  with  appar- 
ently an  uneventful  recovery.     .Alarcello  Malpighi,^^^'  the 
discoverer  of  the  lym].hoid  follicles  of  the  spl.en  had  pre- 
viously described  the  effects  of  ligating  the  splenic  vessels 
of  a  dog.     It  not  only  quickly  recovered  from  the  oi>era- 
tion,  with  no  noticeable  injury  to  health,  but  became  more 
voracious  and  much  lazier  and  fatter.    Nothing  abnormal 
was  noted  in  the  stools.    A  second  operation  on  this  d.x. 
performed  some  time  later,  showed  almost  complete  dis- 
appearance of  the  spleen,  but  no  other  clianges  except 
slight  enlargement  of  the  liver  and  engorgement  of  the 
n.csentenc  vessels.       Clarke-^   successfullv  extirpated  a 
<log  s  spleen  m  1(576,  and  during  the  vear  following  found 
no  changes  except  that  the  animal  became  much  fatter 
The  celebrated  pathologist,  .Arorgagni,=»»  states  that  he 


A-.Y-fl, 


EXTLRPATION  OF  THE  SPLEEN  5 

and  Vallisnerius  found  duriiiy  a  period  oi"  five  years'  studv 
no  change  in  the  size,  disposition,  or  fertility  of  dogs  whose 
spleens  had  been  removed.  J.  H.  Schultze  •""'  early  prac- 
tised splenectomy  on  dogs  with  a  view  to  the  application 
of  the  operation  to  human  beings.  Harvey  and  his  pupils 
are  frequently  quoted  as  having  extirpated  the  spleen  in 
dogs,  but  we  have  not  been  able  to  find  such  accounts  in 
Harvey's  works. 

Observations  on  experimental  splenectomy  are  more 
numerous  in  the  nineteenth  century.     Assolant,""  found 
that  in  dogs  the  blood  became  more  watery,  with  the  ap- 
I)earance  of  scurvy-like  symptoms  and  fatal  peptic  ulcer. 
He  states  that  Dupuytren  lost  almost  half  of  forty  dogs 
after  splenectomy.    Those  that  survived  recovered  ii.  two 
or  three  weeks  and  acquired  abnorn'.al  appetites.     Spitta 
and  JNIayo  found  increase  in  weight,  and  Mayer  increased 
tendency  to  sleep.     Saunder;   reported  no  change  in  bile 
formation.      A.    S.    Schultze  •''•'••    removed   the   spleen    of 
twenty-four  animals   (dogs,  cats,  goats,  rabbits),  losing 
only  one  puppy.    Tie  states  that  the  operation  is  followed 
by  lessened  fertility,  greater  inclination  and  ability  to  run 
far,  and  at  first  a  decreased  secretion  of  bile.     Czermak,*" 
working  with  dogs,  rabbits  and  cats,  found  that  two-thirds 
of  the  animals  survived,  and  showed  lessened  fertility  and 
enlargement  of  the  mesenteric  lymph-nodes.     He  "noted 
th.it  the  spleen  became  gre:it'y  congested  after  feeding. 
Vulpian,^""  on  the  other  hand,  found  no  change  in  fertility. 
Enlargement  of  the  lymph-nodes  after  splenectomy  was 
noted  by  Tiedemann  and  Gmelin,^''^   Hyrtl,'"-  Mayer, ='*'* 
Fiihrer  and  Ludwig.'''-  Eberhard,'""  am'  Simon.^"" 

Maytr  maintained  also  that  the  extirpated  spleen  was 


•  THE  SPLEEN  .\ND  ANEMIA 

easily  replaced  by  a  newly-formed  organ.    This  was  con- 
hrn.ed  by  El)e,-hard,  working  on  the  frog,  and  by  certain 
l^rench  and  Italian  investigators    (Philippeaux,^"'"  Eter- 
nod.'^'^    Tizzoni,'^^).       More   careful    later   work    (Pev- 
T'   ]   7'^^""'"^     Ceresole,«='     Tedeschi.'-),     however, 
showed  that  when  the  spleen  had  been  con.pletelv  removed 
no  regeneration  took  place;  bnt,  if  a  small  portion  was 
left  ///  .s7/»,  It  might  hypertrophy  and  sinmlate  complete 
regeneration     (Philippeaux,---     Laudenbach  =-).      Even 
this,  however,  has  been  denied  bv  Pevrani ""  and  Cere- 
sole."-'    Bardeleben  ■■••'  found  that  extirpation  of  both  spleen 
and  thyroid  was  almost  invariably  fatal.    Mosser  =^"==  noted 
a  stimulation  of  the  bone-marrow. 

Thus  we  find  that  bef(,re  the  year  187.5  numerous 
experimenters,  working  on  dogs,  cats,  goats,  rats,  mice, 
gnmea-p.gs,  sheep,  rabbits,  frogs,  and  one  (Eternod)  on 
a  fox,  had  found  that  the  spleen  was  not  necessary  to 
life.    Though  one  out  of  four  splenectomized  animals  died 
(usually    from    j)eritonitis    or    pneumonia),    the    others 
qmckly  recovered  and  enjoyed  good  health.     The  most 
constant  findings  were  increased  appetite  and  eventual 
gam  in  weight.     At  autopsy,  enlargement  of  the  me^en- 
t^ric  lymph-nodes  was  frequently  found,  with  occasionally 
enlargement  of  the  liver,  congestion  of  the  splanchnic  ves- 
sels,  and,  according  to  Mosser  and  Schindler,'^"^  stimulation 
of  the  bone-marrow.    The  power  to  regenerate  after  extir- 
pation  was  denied,   though  it  was  shown  that  if  small 
amounts  of  splenic  tissue  are  left  behind,  these  possess 
great  capacity  for  hypertrophy. 

The  first  recorded  si)lenectomy  on  a  human  being  is 
the  celebrated  operation  performed  in  Naples  in  1.549  by 
Zaccarclli.  at  the  instance  of  Fioravanti,''^  whose  descrip- 
tion follows: 


^-•-''■^;:d.;v-«j-T.-.-:, 


EXTIRPATION  OF  THE  SPLEEN  7 

In  the  month  of  April  I  was  called  to  a  Greek  woman,  the  wife 
of  a  G'cck  centurion,  or  war  captain,  who  lived  at  Panormus,  near  the 
Garden  of  Marinus  de  Terra  Nova.  Her  name  was  Maruella,  and  she 
was  twenty-four  years  old.  Her  spleen  was  stopped  up  (oppilatus) 
and  grew  to  such  a  size  that  the  body  could  not  have  held  a  larger  one. 
She  had  been  visited  by  several  doctors  and  had  been  told  that  if  she 
wished  to  be  cured  it  would  be  necessary  to  take  the  spleen  out  of  the 
body.  The  cajjtain  himself  came  to  me  and  took  me  with  him  to  visit 
his  wife;  she  desired  of  me  the  removal  of  the  spleen.  P'or  this  pur- 
pose I  invited  an  old  man  named  Adrian  Zaccarclli,  from  tlie  town 
of  Palum,  in  the  kingdom  of  Naples,  who  was  very  skilled  in  surgery. 
With  him  I  proceeded  to  the  operation.  The  old  man  made  an  incision 
in  the  body  and  immediately  the  spleen  protruded  from  the  body. 
After  we  had  separated  it  from  the  membranes  we  pulled  it  entirely 
out  and  sewed  the  body  up,  leaving  only  a  little  hole  (spiraculo  exiguo 
relicto).  This  I  cured  with  oleum  hypericonis,  incense  powder,  mastix. 
and  so  on.  In  this  manner  she  was  cured  in  twenty-four  days.  When 
taken  out  of  the  body  the  spleen  weighed  thirty-two  ounces. 

It  should  be  said  that  some  writers  have  doubted  the 
veracity  of  this  description,  and  Simon  has  suggested  that 
on  account  of  the  discrepancy  in  the  size  of  the  tumor 
before  and  after  removal  it  may  have  been  an  ovarian  cyst. 

Two  other  equally  doubtful  reports  of  successful  sple- 
nectomy in  the  sixteenth  century  are  at  hand.  Baillon  ^^ 
tells  in  a  few  words  how,  in  1578,  an  unknown  operator 
removed  the  spleen, 

"  qui  secuit  print  xuperiore  parte  ligaia;  convaluit  ceger.  Este 
igitur  tplentam  necenarius?  "  (Which  he  cut  after  the  upper  portion 
had  been  tied ;  the  sick  man  recove/ed.  Is  then  the  spleen  so  necessary 
to  life?) 

Rousset^**  also  describes  the  successful  removal, 
by  a  certain  Doctor  Viard,  of  a  spleen  which  had  already 
protruded  through  a  wound  in  the  left  side. 

In  the  seventeenth  centurv  two  cases  of  total  removal 


jr^^3^^mammsm^^T^^i^mmsmsmsssm 


8  THE  SPLEEN'  AND  .VN.EMIA 

of  the  spleen  are  reeonJed.     Ti.nothv  Clarke's  ^«  case  was 
reported  l,y  a.i  eye-witness,  Dr.  DovIki.v  Tiirl,evile      A 
certain  W.ll.an.  l>a„ier,  „f  Somerset,  in  an  attempted  sui- 
CMde  drove  li.s  butcher's  knife  into  his  left  side.    The  spleen 
part  of  the  onu-ntmn,  and  the  intestines  protruded  fnun 
the  wound,  and  his  eon.pam.Miv  left  him  for  dead      Three 
days  later  a  surgeon  re,,laeed    ;,e  intestines,  eut  awav  the 
sp  een  and  omentum,   and   sewed   up  the  wound.   "  The 
patient  quiekly  recovered,  was  (,uite  well  a  year  later,  and 
then  nuKratcd  to  New  K,.^dand.  where  he' lived  happilv 
and  m  ^ood  health  for  son.e  years.     The  second  case  wa's 
of  hke  character.     Xieolaus  Mattlna,-'  the  town  sur<reon 
of  Colbert,  .n  1(578,  was  sent  by  the  magistrate  to  a  nei-di- 
bor.n^  town  to  see  a  youn^r  xnan  who  had  beer,  ir.jured 
by  a  kn.f  e-thrust  in  the  left  side  of  the  abdon.en.    Tl.;  nro- 
trudmjf  spleen  was  pulled  er.tirely  outside  the  body  ar.d 
ij^nited.    Three  days  later  the  spleen  was  removed  and  the 
bleeding  controlled  with  styptics.     The  patient  recovered 
completely  m  three  weeks,  and  six  years  later  was  in  ^ood 
nealth. 

Thus  physicians  becran  to  realize  that  the  spleen  was 
not  necessary  for  life.  However,  in  spite  of  several  sirni' 
lar  successful  splenecton.ies  in  the  eiohteer.th  century 
(Gerbezms,  1700;-  Ferrerius,  1711;-  South-Wilson, 
ma  -),  rest,  diet,  salves,  and  blocKlIettin-  were  con- 
sidered the  proper  treatment  for  injuries  of  this  important 
orffan.  The  first  case  of  extirpation  of  the  spleen  reported 
in  America  is  apparently  that  of  O'Brien,^'"  in  181(5  for 
prolapse  following  a  knife-wound.  The  patient  recovered 
completely  in  the  space  of  ei,irht  weeks. 

Another  proof  that  the  spleen  is  not  necessary  for  \[fv 
IS  found  in  occasional  reports  of  congenital  absence  of 


3.,«..-«»4"',-> 


EXTIRPATION  OF  THE  SPLEEN  9 

the  spleen.  In  fact,  these  reports  indicate  that  an  indi- 
vidual may  live  to  -in  advanced  a^e  aiid  exhibit  no  abnor- 
mality traceable  to  the  absence  of  the  spleen.  The  case 
reported  by  Ilodenpyl '«'  exhibited  a  ^^eneral  lymphoid 
hyperplasia,  and  it  is  probable  that,  as  after  splenectomy 
there  is  a  ^rpadual  adajjtation  of  the  l)lood-re<rulatiii 
or^rans,  so  also,  in  the  con^renital  absence  of  the  spleen, 
other  orn-:ins  may  take  on  the  function  of  the  missin^^  organ! 
Since  the  ten  cases  collected  by  Ilodenpyl,  other  authentic 
cases  have  been  reported  by  Kohlhass,--'  Sternberg,^"'  and 
Uiches.'-'  making  a  total  of  13.  Unfortunately,  modern 
methods  of  blood  examination  were  not  included  in  the 
study  of  any  of  these  eases. 

Karl  Quittenbaum,'^""  who  introduced  the  practice  of 
ovariotomy  into  Germany,  was  probably  the  first  to  plan 
deliberate  splenectomy  for  disease  of  the  spleer.  Numer- 
ous successful  splenectomies  on  dogs  and  cats  led  him  to 
believe  that  the  omentum,  whose  vessels  were  always  en- 
larged, took  over  the  function  of  the  .'^pleen.  In  182(5  he 
had  occasion  to  practise  the  operation  on  a  young  woman 
in  an  advanced  stage  of  hepatic  cirrhosis.'  Though  she 
suffered  from  extreme  ascites  and  weakness,  he  yielded 
against  his  judgiisent  to  the  patient's  entreaties,  and  re- 
moved the  spleen.    She  died  six  hours  later  from  shock. 

More  important  in  bringing  the  operation  to  the  atten- 
tion of  the  medical  world  was  anothe-  unsucessful  opera- 
tion, by  Kuehler-^'  in  18.5.-i.  Death  occurred  a  few  hours 
after  operation,  due  to  hemorrhage  from  a  brajich  of  the 
splenic  artery  that  hid  not  been  ligatcd.  This  gave  rise  to 
a  lengthy  controversy  between  Kiichler  and  the  Verein 
Ilessischer  Aerzte,  represented  by  tlie  surgeon,  G.  Simon. 
Efforts  towards  reconciliation  by  Adelmann,  of  the  Tni- 


10 


THE  SPLEEN  AND  ANEMIA 


versity  of  Dorpat,  to  whom  the  matter  had  been  referred 
were  unsuccesslul.    On  account  of  Simon's  greater  repu- 
tation, Ins  opinion  prevailed  that  the  operation  was  justi- 
hable  only  when  necessitate.!  by  an  otherwise  fatal  wound, 
len  years  elapsed  before  splenectomy  was  again  reported, 
this  time  in  England  by  Spencer  AVells,"^  whose  patient 
died  one  week  after  operation,  probably  from  septicaemia. 
Ihe  nature  of  the  enlargement  of  the  spleen  is  not  stated. 
In  spite  of  the  unsuccessful  outcome  of  this  case,  attempts 
at  splenectomy  quickly  became  more  numerous.     Thus 
Schumann,^""  collected  sixteen  cases  hi   1808-   Collier  ^^ 
twenty-nine  in  1882,  and  Adelmaim,^  flftv-three  in  1887 
Since  that  date  the  literature  on  splenectomy  has  been  very 
thoroughly  covered  by  three  authors,  Vulpius  ^«"  (to  18')-t) 
Laspeyres  ^^''^   (1894  to  1903),  and  3Iichelsson  ^-'   (1903 
to  1913)      These  reports  show  that  in  later  years  the  mor- 
tality alter  splenectomy  has  been  materially 'reduced.  This 
IS  due  in  part  to  improvement  in  technic  and  in  part  to  the 
general  abandonment  of  the  operation  in  cases  of  leuke- 
mia,  ,n   which  c(mdition  surgical   interference  is  nearly 
always  disastrous.    For  the  simpler  conditions,  such  as  cyst, 
torsion,  or  wounds  uncomplicated  l)y  copious  hemorrhan-e 
the  mortality  is  almost  nil     The  recent  applications  "of 
splenectomy  to  other  conditions,  as  the  anaemias,  will  be 
discussed  in  later  chapters. 


CHAPTER  II 

EXPERIMENTAL  STUDIES 
THE  EFFECTS  OF  SPLENECTOMY  IN  THE  DOG 

(l)THE  ANEMIA,  (2)  THE  INCREASED  RESISTANCE 
OF  THE  RED  BLOOD-CELLS.  (3)  THE  DECREASED 
TENDENCY  OF  HEMOLYTIC  AGENTS  TO  CAUSE 
HiEMOGLOBINURIA  AND  JAUNDICE. 

The  experimentcal  studies  here  presented  had  for  their 
ohjeet  the  attainment  of  new  knowledge,  and  the  con- 
firmation or  otherwise  of  older  views,  concerning  the  effect 
produced  on  the  blood  by  the  absence  of  the  spleen.  All 
our  experimental  observations  have  been  made  upon  the 
dog. 

The  most  important  changes  after  splenectomy  we  have 
found  to  be  (1)  a  A-arying  degree  of  anfemia,  (2)  increased 
resistance  of  the  erythrocytes,  and  (3)  lessened  tendency 
to  jaundice  when  ha?molytic  agents  are  administered.  Less 
frequent  results  which  follow  the  procedure  are:  (4)  de- 
struction of  erythrocytes  by  the  endothelial  cells  of  the 
lymph-nodes  and  the  liver,  and  (5)  transformation  of  the 
marrow  of  the  long  bones  from  a  yellow  to  a  red  marrow. 
These  several  changes  will  be  presented,  so  far  as  possible, 
in  the  order  named,  and  in  connection  with  them  will  be 
offered  evidence  concerning  the  relation  of  the  spleen  to 
protein,  fat.  and  iron  metabolism,  and  data  on  other  minor 
phases  of  the  general  problem  of  the  relation  of  the  spleen 
to  blood  destruction  and  regeneration.  As  control  studies, 
a  series  of  obser\'ations  are  offered  on  the  results  of  divert- 
ing the  splenic  blood  from  the  liver  without  removal  of 
the  spleen. 

11 


**  THE  SPLEEN  AM)  AX.EMIA 

I.     THE   ANEMIA    FOLLOWING   SPLENECTOMY 
This  is  Of  the  type  of  the  so-railed  secorulurv  ana^ia 
chnraeten^d  by  a  decrease  in  the  number  of  rcj  cellsTj 
the  ha.n.oglob;n  content,  witi.  little  evidence  at  fi    t  of 
regeneratn-e  changes.     In  n.any  instances  the  an.n.t- 
develops  almost  imn.ediately  and   progresses  ^rraZllv 
unt,   about  the  end  of  the  lir'st  n.onth,  ^LT     re     h        ; 
pomt  of  greatest  severity ;  the  return  to  nonnal  then  h     in 
and  a  blood  condition  sin.ilar  to  that  before  splenectomy 

TARLE  I  *  t 
_^'^°  ^^^i-  Cor.vrs  After  Splenectomy 


Prelimi- 
nary cuuc 


Dog  32    I    Dob  33 
I  5,340,000  I  -,,'J30,000 


4,r,(m,i)(X) 

•1,7()0,00() 
4,470,0(W 
4,()20,000 

4,NK),()()(y 

4,()I0,(HM) 

4,()0(),0(XJ  5,980,000 
3,1«)0,()00 


Dog  41      I    Dog  44 


5,350,000     5,150,000 


3,550,000, 


4,540,()(M) 
4,710,(KX) 
4,700,000 
4,070,000 
0,920,000 
•■J,.S40,00(): 
.■i,50(),(KX)l 
3,200,000 


3,720,000, 

3,970,000 
4,240,(NJO 

4,890,0fX) 

I 

5,35(),(KX) 

5,100,000 
5,230,(HX) 

6,120,000 


2,890,000 
4,790,00013,050,000 


4,4,50,000 
5, 090,  (XX)! 
4,S()(j,(XX)i 
'5,120,000 
5,0(iO,00(j| 
4,310,(XK»: 
3,720,0<X) 
3,.')(XJ,000' 
3,390,000 


Dog  46         Dog  57     I     Dog  59 


5,520,000      5.520,000     4,610,000 


5,820,000' 
5,5iK},(KXJ 
0,310,000 


3,5,50,(XX)! 
4,(){X),(X)0 
•'■>.020,(KX)i 
i4,(XX).(XX)* 
4,1!«),(XX) 
4,30(),(XK) 
3,»)S0,(KX)! 
3,8(iO,(KW)| 
4,(XX),00()' 
4,2()0,(K)(r 
l,;ilO,(XK) 
4,S00,0(K) 
5,  IS  1,000 
5,3i-iO,000 


2,8S0,O(K) 
3,010.(KX) 
3,2(K),(XX)! 


5,700,000 
3,220,000, 5,3,so,{XK). 
5,280,{KKJ 
4,9(iO,(HK): 
4,580,000, 


5,100,000 
5,120,(X)0 

|5,I25,O0Oi 

3,940,000^ 
3,810,000; 
4,280,(XX)! 
4,4-10,0(X)' 
4,390,0(X)i 
3,150,000 


4,140,00) 

3,0<K),(XX) 
i  2,;j90,(KX) 

3,120,000 
'  3,9tiO,000 

4,210,000 

4,000,000 


3,100,0001 
3,080,000 


3,9S0,000|  4,740,000 
4,9-,0,000j  4,740,(XK) 

5,240,000  4,.';00.000 

i,tiio,(MX)  4,]rmm 

5,2:iO,(X)o' 4,4(10,000 
5,4<X),(KX)  4,970,(KX)i 


3,560,0(X) 

2,970,(XX), 

3,2(X),000, 

4,100,(KX), 

4,210,0(X) 

4.710,(«K) 

5.0I0.(HK)' 

4.(;,M),(I(K) 

5,9,S0,000l 

5,320,0(X): 

5,lS0,(XX)i 

5.210,000' 
5,21(;,(XX) 
5,1(M),(H)0 
6,0.5(),(XH)| 


4,4(iO,000 
3,S(>0,(HK) 
4.120,000 
i4,510,(X)O 
4,010,000 
4,49(),(KX) 
4,570,0(X) 

4,9,V(),(,y)0 
4,7(X),(XX) 

1.340.  (XX) 
5, 1(M),00() 
5,4(K),(XX) 


(!,2.'-)0.000 
5,5.5().(XX) 


t  liI'o,i!f"T>  ","'  ""'  ''"I"'""  '"for 
to  the  Picture  oMI„.b|,.,„|',,,,;;^'.'j'|; 


f  hi.-ontn'^l^^yj'^Al"^-!"^^  ""''■"-«"">>•, 


<ve  lieen  innitted 


■  nt.TvenuiK  ,,.„m..  ,l,;,i  f„ii  ,,,  ,„),, 


*S»-«j^  *''^***  ^- 


EXPERIMENTAL  STUDIES 

is  reached  after  two  and  a  half  to  three  months.  Rarely 
the  onset-'"  of  the  ana?inia  may  be  delayed,  and  not  infre- 
quently the  lowest  point  is  not  reached  for  six  weeks,,  and 
the  return  to  normal  delayed  until  four,  five,  or  six  months, 
or  occasionally  until  even  longer  periods.  In  some  instances 
there  is  an  actual  rise  of  ha\moglobin  and  red  blood-cell 
count  for  several  days  after  operation.  This,  however,  is 
found  after  other  operations  of  similar  intensity  and  prob- 
ably has  nothing  to  do  with  the  removal  of  the  spleen. 


Km.  l.-C<.,nposito  curve  of  tlu.  r.,1  hlooM-pcll  count  of  .ov-n  dogs  after  eplenectomy. 

The  figures  of  Table  I  show  in  general  a  ])rompt  onset, 
a  gradually  increasing  aniumia,  and  a  slow  return  to  nor- 
mal. An  irregularity  is  seen  in  Dog  40,  wliich  failed  to 
show  a  fall  in  the  red  cell  count  until  one  month  had 
elapsed,  and  also  in  Dog  44,  in  which  the  normal  level  had 
not  been  reached  after  ten  months.  Cerlain  nn'nor  Huctua- 
tions  are  evident  iiere  and  there,  but  in  general  the  ana-mia 
takes  a  definite  course. 

As  a  rule,  the  decrease  in  h.xmoglobin  sets  in  a  little 
Inter,  but  is  eventually  more  marked  than  the  fall  in  the 
red  cell  count;  als(».  as  improvement  l)egins,  the  erythro- 
cytes increase  more  rapidly  than  docs  the  httmoglobin. 


14 


THE  spli:en  and  anj<mia 


The  red  cells  seldom  drop  below  3,000,000  or  the  haemo- 
globin below  5.5  per  cent.  Not  infrequently,  when  the 
blood  picture  has  returned  to  normal,  the  figures  are  higher 

TABLE  11 
Hj:Moau)Bi.\  Estimations  After  Splenectomt 


Prelirni- 

Dog  32    '     Dog  33 

Dog  41     ;     Do({  44 

Dog  46 

1     Dog  57 

Dog  59 

iiiation 

lOOpcrcent 

9Sperceul 

aOpercem.^lUopercent 

i>S  per  cent 

-1 

•  94  per  cent 

.  SO  per  cent. 

1* 
3 
5 
7 

90 

85 
SO 
80 

70              92 
70       ,       92 

70       1       82 
70              82 

105 
95 
S3 

70 
64 

48 
55 
65 
65 

9 
12 
15 

80 
75 
70 

88 

70 
70 
70 

i       72 
72 

1       02 

85 

98 

77 
62 
70 

18 

65 

70 

'       00 

104 

77 

70 

21 

65 

58 

70 

24 

05 

60 

98 

71 

27 

50 

55 

90 

30 
30 

70 

80 

oo 

57 

95 
68 

55 
50 

70 

42 

48 

70 

52 

58 

55 
55 

70 

75 

61 
76 

80 
76 
74 

64 
60 

80 

78 
82 

05 

72 

84 
89 

66 

90 

78 

70 

75 

90 

78 

72 

80 

90 

70 

79 

90 

80 

84 
82 

75 

88 

78 

94 

72 

!K> 

()6 

90 

97 

88 

104 

90 

62 

85 

94 

124 

95 

75 

80 

D5 

90 

150 
210 

97 

94 
100 

85 
75 

68 

110 
104 

105 
105 

300 

102 

1 

92 

81 

108 

•  The  fi( 

sures  in  the 

6rat  cfjlumc 

refer  to  th 

e  number  o 

days  after 

splenectom 

y 

than  Ufore  splenectomy.  This  is  true  of  both  the  red 
cells  and  the  hiiMiioglobin.  Lamson  ^"^'  has  recently  shown 
that  strong  emotions,  such  as  rage  or  fear,  by  stiinulating 
adrenalin  secretion  and  thus  changing  the  concentration 
of  the  blood  constituents,  can  produce  considerable  changes 
in  the  red  blood-cell  count  per  cubic  millimetre.     In  the 


EXPERIMExNTAL  STUDIES 


U 


animals  whose  blood  counts  are  here  reported,  however, 
various  observations  indicate  that  such  disturbing  factors 
need  not  be  considered.  In  the  first  place,  the  amount  of 
emotion  produced  in  the  process  of  securing  blood  counts 
is  slight,  temporary,  and  often  almost  entirely  absent.  Fur- 
thermore, normal  animals  have  been  followed  over  consid- 
erable periods  of  time  without  appreciable  change  in  their 
blood  counts. 


hemo 
Qlobin 

Be]-ore 
Splenec- 

After Splenectomy   Time  in  Da,ys                                    i 

tomy 

1 

3 

5 

7 

9 

12 

15 

18 

21 

24 

21 

30 

36 

At 

46 

54 

GO 

6672 

eo 

68 

96 

\M 

124 

isi 

MC 

100% 

95  7, 

1 

,A, 

90% 

N. 

\/' 

-" 

851 

^ 

V 

f— 

^ 

> 

1 

80  i 

\ 

/ 

^ 

/'^ 

s/ 

75Z 

\ 

V 

70X 

V 

-r 

v 

^ 

^ 

&5% 

V* 

•^ 

J 

60Z 

_j 

_j 

_i 

Fij.    2. — Composite  curve  of  the  hasmoiilobin  estimation  of  peven  dogo  after  pplenectomy. 

The  nature  of  the  ana:mia  that  follows  splenectomy 
will  be  discussed  later  (see  page  87),  after  some  other 
factors  which  are  dependent  upon  the  removal  of  the  spleen 
and  have  a  possible  relation  to  the  anaemia  have  been  pre- 
sented. Here  it  may  be  stated,  however,  that  the  stage 
of  repair  is  not  characterized  by  the  constant  appearance 
in  the  peripheral  blood  of  nucleated  or  other  abnormal 
types  of  red  cells.  Careful  differential  counts  of  the  blood 
of  three  dogs  at  regular  intervals  for  138  days  failed  to 
reveal  in  two  the  presence  of  nucleated  red  cells,  and  in 
the  other  tliey  were  demonstrable  only  five  times,  the 
largest  number  seen  in  one  count  being  three.    In  none  of 


16 


THE  SPLEEN  .\.\D  .IN.iiMLV 


these  animals  were  othe-  changes  evident  in  the  red  cells, 
except  tlie  pale  stauung  corresponding  to  a  low  h^nioglo- 
hm  content.     In  a  large  number  of  other  animals  in  which 
differential  counts  were  made  at  irregular  intervals,  changes 
in  the  red  cells  have  been  found  very  rarelv,     Tims  in  one 
dog,  hve  weeks  after  splenectomy,  f.ve  normoblasts  and 
one  megaloblast  were  found  (in  counting  100  leucocvtes) 
as  was  also  evidence  of  poikilcK-ytosis  and  polvchromato- 
philia,  and,  a  vyeek  latc^-,  one  normoblast  and  one  megalo- 
hlast.     Ihese  hnd.ngs  were  in  the  first  davs  of  begin'.in.r 
repair,  the  red  cells  and  ba>moglobin  having  a  few  dav^ 
heore  reached  the  lowest  level  obsened  .luring  the  expeiV 
nent    haemoglobin,  50  per  cent.;  red  cells.  2,970,000.     In 
another  dog.  two  months  after  splenectomy,  again  at  the 
stage   of    b'.'gmmng   repair    (ha<moglobin,   (32;    red   cells 
.•MoOOOO),    five    nucleated    red    cells    were    found,    and 
polychromatophilia  was  evldvut    In  no  instance  di.l  these 
findings  persist  for  any  length  of  time.     Thev  are  of  s,> 
n.ficance  only  in  that  they  probably  indicate  the  period  of 
begmning  repair.  ^ 

The  very  definite  nuclear  particles  found  bv  .Arorris  ^""' 

"  m-  •;"■  '"  ^"' • '''''''-''  '■"  '''''  ''"^''  ^^"^Pit^  -Teated 
txannnatK.ns  made  smce  Morris's  second  publication    This 

The  number  of  skeined  or  reticulated  ervthrocvtes  is 

ery  shglitly,  ,f  a-  all.  increase,]  during  the 'earl v 'stal 

follow,ng  removal  of  the  normal  dog's  spleen.     Gates^-' 

on  the  other  hand,  has  shown  that  there  is  an  increa      in 

the  number  of  reticulated  cells  when  the  nna-mia  is  greates" 


>:  i'. 


EXPERIMENTAL  STUDIES 


17 


that  is,  just  before  the  period  of  beginning  repair.  The 
blood-phitelets  also  are  only  slightly  increased  after  re- 
moval of  the  normal  spleen. 

White  Ceils. — As  our  problem  was  one  concerning 
the  red  rather  than  white  cells,  the  latter  have  not  been 
studied  as  thoroughly  as  have  the  red  cells.  We  have,  how- 
ever, total  leucocyte  counts  of  five  dogs  and  differential 
counts  of  three  dogs,  in  each  instance  covering  long  periods 
of  time,'" '  and  on  many  others  for  shorter  periods.  The 
results  of  the  total  leucocyte  counts  are  presented  in  Table 
III  and  Fig.  3,  and  of  the  differential  counts  in  Table  IV. 

TABLE  III 

Leucoctte  Count  After  Splenectomy 


Preliminary 
count 


!• 

3 

5 

7 

9 

12 

15 

18 

21 

24 

27 

30 

36 

42 

48 

54 

60 

66 

72 

80 

88 

96 
104 
i24 
240 


DOK32 


y.ooo 

26,000 
26,000 
28,000 

2r,,ryx) 

28,000 
22,000 
25,0(X) 
19,(X)0 
18,000 
15,000 

33,000 

16,000 

11,000 

13,000 

14,000 

13,000 

15,000 


n  g  I     1 


Dog  44 


12,000 


33,000 
22,500 
21,0(K) 
23,000 
19,000 
21,0(X) 
18,000 
19,000 
U,000 

15,000 
15,000 

11,0(X) 
12,000 
11,000 


12,000 
12,000 

13,000 

13,000 


13,000 


36,000 
21, .500 
13,000 
13,000 
14.000 
13,000 
16,000 
18,100 
16,400 

12,0(X) 
14,200 

11,200 

10,000 

11,200 

0.000 
11,000 

12,400 


Dog  57 


Dog  59 


14,400 


14,200 


38,100 
21,100 
17,000 

22,000 
19,200 
19,600 
18,700 
18,400 
18,600 

10.000 
16,900 
19,000 
19,200 
15,000 
16,100 
17,600 
16,400 
16,000 
18,100 
20,100 

16,000 
16,400 


28,700 
13,800 
11,400 
17,900 
14,400 
17,800 

16,800 

12,100 
11,800 
13,400 
15,300 
12,100 
17,400 
13,100 

11,600 
12,200 

1.3,600 
9,000 


K5,000 


*  The  figures  in  this  column  refer  to  the  number  of  days  after 
splrnectomy. 

2 


18 


THE  SPLEEN  AND  ANJ^MIA 


The  leucocyte  picture  was  quite  constant.  On  the  day 
after  splenectomy  the  white  cells  rose  from  a  normal  level 
of  9000-14,000  to  38,000  per  cubic  niillin.etre,  or  even 
higher,  and  in  a  few  days  fell  rapidly  to  about  20,000,  after 
which  there  was  a  more  gradual  decrease  with  return  to 
approximately  the  normal  level  after  a  period  ranging  from 
one  to  four  months.  The  initial  leucocytosis  was  due 
mainly  to  an  increase  in  the  polymorphonuclear  neutro- 
philic leucocytes,  and  was  probably  a  post-operative  effect 


Fia.  3— Composite  curve  of  the  leucocyte  count*  of  five  d">rs  after  splenectomy 


and  not  due  to  the  specific  absence  of  the  spleen.  Lympho- 
cytosis, although  usually  described,  has  been  found  only 
to  a  slight  degree  in  this  series.  At  no  time  were  the 
lymphocytes  recorded  as  higher  than  34  per  cent.,  while 
the  average  count  in  all  dogs  was  about  18  to  26  per  cent. 
In  the  parallel  observations  on  the  results  of  diverting  the 
splenic  blood  from  the  liver  without  removal  of  tlie  spleen, 
the  early  polymorphonuclear  leucocytosis  and  later  lym- 
phocytosis were  also  noted.  The  behavior  of  the  eosino- 
philes  has  varied;  in  two  dogs  (not  presented  in  Table  IV) 
an  eosinophilia  of  10  to  32  per  cent,  persisted  for  113 
days  in  one,  and  in  the  other  an  eosinophilia  of  6  to  11 


EXPERIMENTAL  STUDIES 


19 


TABLE  IV 
Differential  Cocnts  of  White  Cells  Aftek  Spu:.\ectomt 
Dog  I 


Time 

Leucocytes 

Polj-nudcars 

t 

Lympho- 
cytes 

t 

Kosinophilea 

t 
Other 
forms 

Ik-fore  operation 

12,500 

8,025 

3,000 

500 

375 

•1 

4,5,200 

37,100 

5,SS0 

4.50 

1,770 

3 

22,400 

17,2,50 

■i;MA) 

5t)0 

1,2:50 

7 

2,'),  GOO 

1S,700 

4,340 

1,280 

1,280 

13 

2,5,100 

19,,500 

4,UXJ 

1,000 

500 

21 

IS,  000 

13,580 

4,4(K) 

370 

190 

33 

17,100 

11,9,50 

4,:<tiO 

0 

790 

47 

14,500 

10,140 

4,-  JO 

0 

3fi0 

68 

13,000 

9,590 

3,4()0 

0 

550 

82 

14,700 

11,2.50 

2,8<i0 

150 

440 

96 

13,100 

9,500 

2,3(iO 

785 

395 

111 

12,700 

8,(KX) 

3,230 

700 

770 

13S 

15,900 

9,700 

2,380 

2,070 

1750 

Dog  2 


Before  operation 

•1 
3 
7 

13 

21 

33 

47 

68 

82 

96 
111 
138 


10.100 


48,400 
25,100 
23,100 
1S,2(K) 
10,800 
15,1(XJ 
12,000 
11,400 
12,0(X) 
ll,y(X) 
11, 8W 
10,100 


7,770 


43,570 

19,300 

17,7.50 

13,t)50 

12,G(X) 

11,180 

9,350 

8,780 

9,340 

8,300 

8,.5.50 

11,110 


i,6i; 


200 


515 


2,905 

240 

1085 

3,890 

1,510 

400 

4,430 

230 

690 

3,640 

90 

820 

3,700 

0 

500 

3,470 

0 

450 

2,750 

0 

500 

2,280 

0 

340 

2,700 

0 

500 

2,010 

300 

570 

1,770 

7(X) 

720 

1,770 

1,010 

1,610 

Dog  3 

Before  operation 

12,500 

8,650 

3,380 

190 

280 

•1 

2(),900 

21,480 

3,500 

1,070 

8.50 

3 

21,100 

1.5,7.50 

4,720 

210 

420 

7 

12,2(X) 

8,800 

2,6.50 

250 

500 

13 

1(),1(X) 

11,350 

4,520 

0 

2;?o 

21 

14,100 

9,8.50 

3,590 

0 

WK) 

33 

It.KX) 

10,.800 

2,820 

0 

420 

47 

12,  KM) 

8,00. 

3,200 

0 

240 

68 

12,()(X) 

8,4(K) 

3,300 

0 

210 

82 

10.:i(H) 

7,420 

2,ti.SI) 

0 

2(K) 

96 

i;{,i()o 

8,.540 

3,.5.M) 

4.50 

.580 

111 

13,700 

9,040 

3,500 

410 

690 

138 

13,800 

9,0t» 

1,930 

410 

1,800 

the  o*tlH  r^'/.'^l^n  n"  "'!'  ^"'^  ,';"'>™"  indicate  the  nun.ber  of  .lays  after  operation;  n.,n,l,ers  in 
the  ottur  CO  iinm«  in|iic,itc  ihe  nui.ilicr  of  cells  per  cubic  millimeter. 
T  Calculated  on  basis  of  I'lXJ  cells  counted. 


80 


TilE  SPLKEX  AND  AN.K.MIA 


per  cent,  for  107  days.  On  the  other  hand,  in  three  dogs 
the  eosinophiles  disappeared  entirely  ior  long  periods  of 
time,  cor  sponding  roughly  to  the  third  to  eleventli  week,* 
but  this  disapj)earance  was  followed  later  hy  an  increase 
varying  from  (J  to  20  per  cent,  of  the  total  white  cell  count. 
This  disappearance,  as  may  he  seen  in  Tal)le  1\',  corre- 
sponded to  the  i)oint  of  severest  ana-mia  (thirty-third, 
twenty-first,  and  tliirteenth  (hiys),  and  the  reappearance 
to  the  period  wlien  the  blood  has  returned,  or  nearly  so,  to 
its  normal  level  (eighty-second,  ninety-sixth,  ninety-sixth 
day).    As  to  its  significance  wc  have  no  opinion. 

In  all  diffeiential  counts  especial  search  has  been 
made  for  unusual  cells,  as  myelocytes.  These  have  seldom 
been  found.  In  the  counts  shown  in  Table  IV,  represent- 
ing three  different  dogs,  basophilic  myelocytes  were  ff)und 
only  four  times,  and  no  other  atypical  leucocytes  were  seen. 
In  a  fourth  animal,  two  months  after  splenectomv,  baso- 
philic myelocytes  (5  to  100  cells)  were  found  once  at  the 
period  of  beginning  repair. 

The  literature  of  experimental  splenectomy,  while  it 
presents  rather  widely  varying  results,  is,  on  the  whole,  in 
accord  with  our  experience.  Dissimilar  results  are  re- 
ported by  Paton,  Gulland,  and  Fowler,' '"  who  state  that  in 
the  dog,  cat,  and  rabbit  the  removal  of  the  spleen  has  no 
influence  on  the  red  corpuscles.  An  examination  of  their 
tables  shows,  however,  that  in  the  dog  they  did  obtain  a 
slight  anaemia,  a  decrease  of  <iOO,000  to  800,000  red  cells, 
which,  however,  occurred  also  in  one  instance  in  a  norm  1 
dog.    3foreover,  they  used  puppies  about  two  and  a  htw 

*  In  one  of  our  papers"'  in  which  wc  refer  to  this  phenomenon,  the 
period  is  piven  as  "  the  third  to  the  eleventh  day."  This  is  incorrect 
and  should  read  "  week  "  instead  of  "  day." 


mB^^L^^H- 


EXPERIMENTAL  STUDIES 


21 


niontlis  old,  and  it  is  possible  that  in  such  young  animals 
the  mechanism  of  hlood  destruction  and  regeneration  may 
not  l)e  the  same  as  in  older  dogs.  Our  observations  were 
mostly  upon  full-grown  dogs,  but  in  the  few  puppies 
studied  the  results  were  substantially  the  same.  Other 
results  not  in  accord  with  ours  are  those  of  Azzurrini  and 
Massart,"'  who  made  frerjuent  coun'is  on  four  dogs  over 
periods  of  l.>  to  18  months  after  splenectomy.  In  none 
was  a  drop  of  more  than  .5  per  cent,  hivmoglohin  or  100,000 
red  hlood  corpuscles  note<l.  In  this  connection  we  ma)' 
point  out  that  wliere  auicmia  fails  to  develop,  the  possi- 
bility of  accessory  spleens  which  are  sometimes  found  in 
the  dog  must  be  considered.  Zanda,^"*  for  instance,  failed 
to  find  the  usual  changes  after  splenectomy,  and  states 
that  this  was  due  to  the  presence  of  accessory  spleens. 
Diet,  as  we  will  show  later,  also  has  an  important  iiiHuence 
on  the  degree  of  ana'iuia.  Wolferth  ^' '  has  recently  shown 
that  the  same  changes  occur  in  the  blood  of  Albino  rats 
after  splenectomy  that  we  have  found  in  dogs.  In  eight 
rats  which  had  abnormally  large  spleens,  splenectomy  was 
followed  by  rapid  severe  ana?mia,  hyperleukocytosis, 
marked  increase  in  the  numlK^r  of  nucleated  and  reticulated 
cells,  and  proved  fatal  in  seven  of  the  eight. 

Picard  and  Malassez,-''-  by  the  crude  methods  of  early 
blood  examination,  found  a  diminution  in  both  red  cells 
and  hiemoglobin,  but  considered  the  latter  to  be  more 
definite.  Vulpius,^""  (iibson,''"  Laudenbach,^^''  Grigo- 
rescu,*'^  AVinogradow,^'^  and  Tauber*^*  record  a  decrease 
in  red  cells  after  splenectomy  in  the  dog,  and  Vulpius 
describes  a  leucocytosis,  as  does  also  Gibson.  The  degree 
of  ana?mia,  as  well  as  its  severity  and  the  time  of  repair 
as  observed  by  these  different  investigators,  varies  widelv, 


22 


THE  SPLEEN  AND  AN.KMIA 


but  they  arc  in  ^reneral  accord  as  to  hoth  aiucmia  and  Icuco- 
cytosis.    'i'hat  ana-niia  occurs  in  otiicr  animals  than  the  do.' 
IS  shown  I.y  Warthin's  "^'  observations  on  the  sheep  and 
goat.     On  the  other  hand,  the  changes  in  the  rabbit  and 
KU.nea-i)i^r  are  not  so  unifonn.    Ciabbi  '■'  found  in  guinea- 
pigs  an  increase  in  red  cells  and  ha-iuoglobin,  and  in  tlie 
rabbit  no  chan-e  or  a  sli^rj.t  decrease,  as  (hd  also  Zezas.^**'' 
In  the  rabbit  and  cat,  Paton.   (iulland,  and   Fowler"" 
found  no  chancres.    Asher  and  Sollhcrger  '^  have'recentlv 
stated  that  in  the  rabbit  removal  of  the  spleen  causes  an 
increase  of  both  red  cells  and  ha'mo^rl„bin,  and  that  this 
increase  is  due  to  the  removal  of  the  normal  hun.olytic 
activity  of  the  spleen  and  to  stinnilation  of  the  bone-n'ia-- 
row.    Their  observations,  however,  were  made  only  a  sho 
period  after  splenectomy,  so  that  the  rise  noted  may  be 
smnlar  to  that  occasionally  found  bv  us  in  dogs  immedi- 
ately after  splenectomy.     Most  of  the  obser^'ations  con- 
cerning the  ana?mia  following  splenectomy  are,  in  fact, 
incidental  to  other  problems  or  are  based  on  occasional 
examinations,   which  i)erhaps  accounts  for  some  of  the 
discrepancies.     We  feel,  however,  tluit  u.  Ihe  large  num- 
ber of  animals  which  we  have  studied  it  is  conclusively 
shown  that  a  secondary  anjemia  of  some  degree  is,  in  the 
dog  at  least,  a  characteristic  result  of  splenectomy.     The 
variations  in  the  degree  of  ana^nia  are,  however,  so  marked 
that  we  have  made  a  prolonged  study  of  the  influence  of 
diet  ■'■■'■   in  the  hope  of  explaining  these  variations 

Ivf/neucc  of  Diet  ov  the  Amnnia.~ln  these 'studies 
we  had   in   mind:     (1)    the  observations   of   Asher   and 
Vogel."*  that  while  an  iron-poor  diet   (sugar,  starch  and 
lard)  has  no  effect  upon  tlie  hlood  picture  in  a  normal  dog 
in  the  splenectomized  dog  on  the  same  diet,  a  great  decrease 


!^*^^v>^*«-  .:^)^T-''^)m^:'im^^Wl- 


EXPERIMENT.\L  STUDIES  18 

m  numb'^r  of  red  cells  and  iunouut  of  ha'inoglobin  occurs; 
and  furtlier,  if  un  I^t  the  latter  circumstancej  an  iron-rich 
(llesh)  diet  is  ^iven,  the  hlood  picture  (juickly  returns  to 
normal;  {'2)  Kichet's  •"*  observation  that  in  order  to  main- 
tain splenectomizeii  dogs  at  the  same  weight  as  normal 
dogs,  a  much  larger  ((uantity  of  focnl  is  necessary,  and  (3) 
Paton's '-'•'  conclusion  opposed  to  that  of  Richet,  that 
splenectomy  in  the  dog  has*  no  influence  upon  general 
metabolism. 

In  regard  to  Asher  and  Vogel's  contention,  we  have  not 
found  by  a  direct  quantitative  study  (see  page  112)  of 
the  elimination  of  iron  that  splenectomy  seriously  influ- 
ences iron  metabolism."  Moreover,  in  our  opinion,  the 
time  of  improvement  in  the  anjemia  which  these  investi- 
gators descri})e  as  the  result  of  feeding  iron-rich  food 
corresponds  to  the  spontaneous  repair  of  the  ana?niia  which 
usually  begins  about  the  end  of  the  fourth  week.  In 
other  words,  the  improvement  was,  in  our  opinion,  due 
in  part  at  least  to  the  normal  repair  and  not  to  the  effect 
of  the  iron-rich  food.  Their  conclusions  would  be  more 
convincing  If  they  iiad  prevented  entirely,  or  lessened,  the 
severity  of  the  anaemia  by  beginning  the  feeding  imme- 
diately after  splenectomy  instead  of  waiting  nearly  three 
weeks.  As  to  Richet's  point,  it  may  be  noted  that  we  have 
not  seen  noteworthy  changes  in  the  weight  of  our  splenecto- 
mized  animals.  p\)r  a  few  days  after  splenectomy,  a  slight 
loss  may  occur,  but  in  all  long  time  experiments  an  in- 
crease beyoFKl  the  original  weight  has  been  observed. 

The  studies  of  Paton  and  his  associates  as  to  the  changes 
in  the  blood  after  splenectomy  are  the  most  carefully 
conducted  of  any  in  the  literature  and  for  this  reason  we 
have  been  greatly  disturbed  that  our  results  were  so  differ- 


ti 


THE  SIMEN  .\M>  .LN^KMU 


ent.    Their  studies,  l.owever,  were  ]i,„ite,l  to  two  spleneeto 
nnzed  an,n,als  and  two  eontrols  and  it  „,av  tTlZt 
e,,a„ee  the   o„,,cr  eorrespond  to  the  ,„iider  aL„  ias  whitl 
« t  observed      In  the.r  studies  of  the  blood  »"  diet  is  not 
ment,„„ed   hut  in  the  n.etabolisn, '-'  work  the  do 's  were 
lor  part  of  the  time  at  least  on  a  meat  (ln>l,  irorT    dirf 
whK-h,  ,f  used  in  the  hlorf  work  also,  nn«ht  ha  ™    e^  i^ 
Asher  and  Vogel  are  correet,  a  factor  in  deel ,    !;,  e 
ana.n„a.    It  ,s  evident  fron,  this  brief  review  that  d  e^n  ay 
be    n  nnportant  factor  in  detennining  the  degree  of  ana"  ,?, 
follownig  splenectomy.  "ian,iniia 

Until  our  special  inyestigations  of  the  influence  of  diet 

ere  undertaken,  all  anin.als,  except  those  „sed  In  t le 

stu,ly  of  ,r„„  ,„et„bolisn,,==  ha.l  been  kept  upon  the  sa    ! 

f:ir'  ''"'r  ""''"?  "'  ""■"'■  ''-»'l. -™ls  and  c . 
tables-„,  all  essentials,  the  "  table  scraps  "  upon  wlii-h 
dogs  are  usually  fed.    This  was  always  " '.plied  i,al" 
ance  .and  each  dog  received  all  he  wou.d''.t.       d  a    ^ t 
records  show  that  the  splenecto,„i.e,i  dogs  .luring  peri^ 
of  .sever.al  n,o„lhs  gaine.l  in  weight  on  this  diet,  ,  e  c^n 
.dered  ,    h.ghly  satisfactory.     However,  we  ,lid  not  k nl 

^t  wfs  ™'""r,?'"'  "!  «"■'  ""-'1  diet  and,  n.oreover, 

»s  .t  wa    esscnt,,lly  a  boiled  ,liet,  it  might  possibly  be 

d  fic.ent  ,„  s„„,e  substance  essential  to  the  proper  fun  tion 

of  the  h™op„,et,e  system.    Therefore,  in  ,, or  first  gro, 

chetary  expernncnts  anin.als  we,-e  placed  on  ealoricall  ■ 

ufficent  d,ets,  the  protein  bcng  furnished  in  the  forn.  of 
beef  he.a,t  beef  spleen,  or  e.,..,„ercial  casein.  an,i  the  fa 
and  carb„l.y<lrate  ...  the  form  of  lard  and  hrea.l  crumb. 
Beef  spleen  was  introduce!  .,.  account  of  its  bu-ge  i™ 
consent  „,  contrast  with  that  of  the  beef  heart  L  t . 
casein.     .Several  blood  exan.inations  were  m.ade  during  a 


EXPERIMENTAL  STUDIES 


C5 


period  of  ten  days  to  two  weeks  before  splenectomy  and 
at  intervals,  never  exceeding  a  week,  after  operation.  In 
Tables  V,  VI,  and  VII,  which  show  the  results  of  these 
studies,  only  the  last  two  blood  counts  of  the  preliminarj'^ 
I)eriods  are  given.  These  represent,  usually,  counts  made 
respectively  1  to  2  and  5  to  7  days  before  splenectomy. 
i\s  the  blood  of  the  several  dogs  was  not  always  exam- 
ined at  exactly  the  same  inter\'als  after  splenectomy,  in 

TABLE  V 
Inflcexce  of  Diet 


Raw  beef  heart,  lard,  and  bread 


i  Weidlil 


e<l  cell 
I'ount 


Days  '  Dog  79  (splenoctomizcd)        Dog  83  (spleuectomired)      Days 


HiBmo-  ,,,  .   ,  ^ 


Red  cell 
rount 


Htemn- 
plobin 


Before  splenectomy 


kilos. 
0.3 


7,930,000 
7,oG0,()00 


\ptrrfnt. 
!      110 
i     114 


kilos. 
8.7 


7,000,000 
7,770,000 


1 

percent.  4-  7 
>7  12-18 
105  j2«-40 
i  10-60 


After  splenectomy 


.5-  7 
10-14 
ls-23 
2ti-33 
:iS-4l> 
4.J-4N 
52-CI 


8  8 

7,420,000 

fl7 

.'vO 

7,!>10,000   1 

7,230,000 

!W 

;,720,0(K) 

().2,'>0,000 

1(8 

8.6 

6,.'i00,000 

li,810,00() 

llf> 

8.7 

7,270,000 

n.8 

.  ,3(iO,000 

KM 

8.3 

6,S80,(XH1 

10  .^) 

l),f;!»0,OIKI 

100 

h..! 

6,2tiO,0(HI 

lU.S 

0,640. OUO 

y.j 

8.0 

6,240,000 

lO.'J 
103 

Itii 
101 

!)7 

<h; 

'.•3 


Raw  beef  heart,  lartl,  and 
bread 


Dog  81  (control) 


Weight 


kilos. 


Hrii  cell   IlEcriio- 
cuunt     I  globin 


10.0 
10.1 


9.1  (i,320,0(X)i 
6,H,50,(K)O 
(),8,><0,(K)() 
6,S(K).000 
6,000,000, 


percent. 

07 

102 


HO 
90 


order  to  shorten  the  table,  only  enough  blood  counts  are 
given  to  show  the  general  trend  of  the  blood  picture.  The 
figures  for  iron  and  of  nitrogen  in  the  diet  are  based  on 
the  average  of  several  estimations  of  the  food  materials 
used.  These  figures  with  a  calculation  of  the  caloric  value 
of  the  food  arc  given  in  Table  VIII. 

By  comparing  Tables  V,  VI  and  VII  it  is  at  once 
evident  that  in  no  instance  did  the  general  nutrition  of  the 
animals  suiTer.  A  slight  loss  of  weight  occurred  after 
operation,  but  this  was  soon  regained.    Also  it  is  seen  that 


w 


THE  SPLEEN  ANO  AX.i:MU 


constant  l.vel  „f  red  cell  an.l  l„™,„sl<iWn  content  as  do  the 
r  .n-spIenectonn.e,l   anin.als.     The  ehanRe.  hLZ,     Z 
Uoss  70.  83.  84  an,l  87  is  so  slight  as  to  he  within  tie?  , 
o    e„or  of  the  n.ethods  of  h,„„,  e..ann-„ation.  i         ,-"; 

l"   Ih      fe,  tT  "  '"Tf.  "'•"'<-■•  >»■'  ™n  here  one  can 
iwnll,  ,efe,  to  the  condition  present  as  a  frank  anicnna 
It  .s,  however,  of  sisniHeance  that  in  all  instances  the  val 

TABLE  VI 

_^ iNFLtE.NCE    OF    DiET 


Ca.scin,  lard,  and  broad 


Day,  j  j>o<5^2_(^pienectom^ .  ^^r^:;;{:;;z:~^ 

(Weight      Red  cell    ;  Hemo-'.^  .  ,, 
I         '      I       rijunt      I  globin  ."'"«'' t 


i   Cawin,  lard,  and  bread 


Before  splenectomy 


kilos. 
10.7 


Days  Dog  80  (control) 


1 

4- 
,,7        '2-.- 

4()-<)0 


Weight    '^'''^  ''fll 
I     count 


9  1 


J*. 3 

U.2 


'  7  >*'>0,000 
i',-<iO,(X)0 
7,020,000 
7,370,0(JO| 
7,1S0,0(K1 


H»nio- 
globin 


percrnt. 
W 
«2 
U(> 
96 
103 


t,ons  arc  nore  marked  than  in  the  controls  and  also  that 
they  usually  occur  after  ahont  four  weeks,  the  period  in 
post.spleneeto„,y  ana,nia,  usually  marked  hv  the  bwesl 
conn  s.  On  the  other  hand,  the  question  arises  are  ,he,e 
results  m  .some  way  due  to  the  diet  il,.,i.  ■  I  1 
character  of  the  die,,  o  t^^^^"        '"""'' 

of  iron'    That  iron  in  the  die!  fsTf      o^s  Z Z,™:; 

S^vT,     ■«",'  '■';*  *!'"'  *""  "'  "-  «>-  »""  "^785    „ 
!f  ;„       "■;       "■'^ '''''■'"•  *'"'■"'  ""'  ">"»»  """rked  Chan  ™ 
of  any  ,n  the  group.    Tlcef  spleen  was  selected  heca  "el 


EXPERIMENTAL  STUDIES 


87 


—  X  O  CJ 

X 

^ 

b     b 

r-.  pi  t.T  ^^  j;-  *.  en 

O  '--1 '—  V.  V  '-I  GO 

j;  ^  y:  ic  in  ti  30 

p  p  p  p  p  p  p 

5  £  5  2  S  jR  2 
—  —  5  3  5  2  0 

CO  00  00 -» 

*■  M  too 

g 

en  00 

to  10 

i— * 

Zn  ^iZn 

jLfi 

>«>.  rfi> 

C5 


to     =J 
to    2 


o)  X  ■—  p  ^i  CO 
10  p  - 1  —  oc  o 
O  P  o  o  o  o 

g2§25Jg 

25p  5  5o 


O  -O  X  Cr  DC  »I 

C;  4*  0<  to  w*  Ci 


b 


-I  X  *.  w  c  to  4» 

CaS  to  —  ^  tX  01  < " 

000  ooo< 


01  OJ 

o  o 


a 


Z3 


2? 


2:3 

DO 

1 

a 
w 

2! 
O 
H 

O 


H 


g 


2« 


THE  SPLEEN  AND  .LNJiMlA 


cmtau.s  a  large  anmunt  of  iron,  accord         ,>  our  analvses 
2So  n.g.  per  1 00  g,  a.ns,  presu,nably  in  1  part  in  or^^an  c 

con.h.nat,on  and  therefore  readily  utih.abk.     F  esiX 
-rt^and  casein,  on  the  other  hand,  contain  onlv  4.6  mg 
and  .2  mg  per  lOO  gnuns  respectivelv,  and  if  iron  is  fn 
m,portant  factor  in  prever.t.ng  an<.,nia  after  .splenectonu" 

TABLE  VIII 
K™oo..v  ..vn  IHO.V  CO.VX..S.  ..„  C...oa.c  V..™  o.  D....  ok  T.„..s 


Dog  Xo 


Actual  tctal  per  day 


Nitrogen 


em. 

79 

6.5 

83 

9.8 

81 

6.6 

82 

13.6 

84 

10.6 

80 

7.4 

8o 

4.6 

S« 

8.3 

87 

6.8 

90 

4.6 

"ic  w„ul,l  n„t  expect  ;,„in,„ls  fel  ,viti,  spleen  to  .,i„nv  the 
•    ."Ke.  evKlen.  ,„  the  ««„,«  .iven  f„,.  D„,,  g,  ,,„,  « 
uih^r.  one  «„uhl  expect  H„n,cs  ,,,,  in  cxpenn.cnl  8T.    The 
.»ng«  ,n  these  llnec  ,„,in,als,  i„  »||  ,,„,|„,|,intv,  re  „ese 
he  vanat,,.,,  to  he expcCe,,  h,  any  «,oup  of  .,„in,als.  TI 
the  a,l„,nn,l,-at,on  of  al,u,.,lant  organic  iron  in  the  for,, 
of  hccf  .spleen.  ,i„l  not  p,,.vc„t  the  ana,nia    i,  i„  accord 
w.th  o„r  .,n,lics  ==  of  i,,„,  n,etaholis„,.  in  the  ah.^e'ce  of 
fc^splccn  „„.!  o, .,,.,1  ,„  „,e  „,neU,sion  of  Asher  an.l 

_0.lftc_otheH«m^^  ,|,e  .,|ijj|„  ,|,„„jj^^  ^,|,,_.,^ 

*  See  page  112.  ~~  - 


EXPERIMENTAL  STUDIES 


20 


occurred  iii  some  of  the  animals,  it  is  impossible  to  avoid 
the  question  as  to  whether  a  diet  adequate  for  the  nonnal 
do^  is  in  some  way  inadequate  for  the  spleneetomized  dog. 
If  the  latter  could  be  demonstrated  the  value  of  our  views 
concerning  the  severer  types  of  ana-mia  following  sple- 
nectomy, based  on  our  earlier  experiments  upon  dogs  fed 
on  a  general  mixed  diet,  would  depend  upon  whether  or  not 
the  inadequacy  of  diet  held  for  all  animals  operated  upon, 
or  only  for  animals  without  a  spleen.  If  anemia  occurred  in 
dogs  fed  on  the  mixed  diet  after  other  operations  than  sple- 
nectomy, it  would  be  at  once  evident  that  the  food,  while 
sufficient  for  a  normal  dog,  was  not  sufficient  for  a  con- 
valescent dog.  On  the  other  hand,  if  the  anii?mia  could 
be  demonstrated  only  after  splenectomy,  there  would  be 
cstai)lished  a  point  of  importance  in  regard  to  the  spleen 
in  its  relation  to  metabolism,  and  our  observations  on  the 
an.Tmia  after  splenectomy  would  not  onl_y  be  substantiated, 
but  would  gain  an  added  importance.  To  settle  this  point, 
it  was  essential,  therefore,  to  study  in  animals  on  our  rou- 
tine mixed  diet  the  effect  of  splenectomy,  and  as  a  control 
some  other  simple  operation  involving  the  removal  of  an 
organ.  Xephrectomy  was  selected  as  an  operation  quite 
analogous,  from  the  technical  point  of  view,  to  splenectomy, 
and  accordingly  two  healthy  dogs  were  placed  upon  ordi- 
nary kennel  diet  for  seventeen  days;  upon  each  dog  a 
nephrectomy  was  then  performed  and  the  animals  kept  on 
tiie  same  diet  for  twenty-three  days  longer;  splenectomy 
was  then  performed  upon  each  dog  and  the  animal  kept 
on  the  same  diet  for  thirty-eight  days  more.  Blood  counts 
were  made  at  frequent  inter\\als  throughout  the  experi- 
ment. Whereas  during  the  seventeen  days  on  the  diet 
before  operation  and  during  the  twenty-three  days  follow- 


80 


THE  SPLEJiX  .YAD  .VS.EM1A 


animal,  after  the  snlene'to  m  h  ^^'  T  "''^'""'^^^  '"  ^'^'^^^ 
fall  in  I.a.n,oo.lol.n  aXed     I  'n""^  ^^  vvell.narked 

--•thy.    aI.o:tlJt    Itlf^^^^^^^  Jtisnote- 

occurred.  ieiat,;clj    sJ,g],t    change    in    weigJit 


July  3 
July  10 
July  18 
July  2V 
Aug.     4 

From   these   ohservi^;,,nc    e 

factory  f„,„,  ,•„,  an  .fj"'""^  ^"■'•l'     <'-'  -  ••.  -..V 

«.at  „n  II,K  .li,.t   ™  •'""  rff""'  operations;   (2) 

"r;ran  other  tl,  n  t^'      ,         ';""''""-'  *'"=  —"1  "fa. 


EXPERIMENT.!!.  STUDIES  si 

IS  c  thti   (a)  because  M.nie  toxic  substance,  which  operates 
m  the  absence  of  the  spleen,  is  present  in  this  paSar 

the  spleen.     In  connection  with  this  last  cr,nc'asion    it 

a  cooked  d,et    ,t  was  possible  that  in  the  cookin.r  there 
occurred  the  destruction  by  heat  of  some  vitan.n-hke  sub 
stance  nonnally  utilized  by  the  spleen.     To "ontrol  t's 

TABLE  X 
The  W...CK  Upo.v  ru.  A...m:.  Fou.ow.va  Sp.....ck.m.  o.  .  R.w  ^„  , 
CooKKD  Diet  ■*'"'  * 


Dng 

No. 


Diet 


Before  Bplenectomy 


■s 

^      a 

■c 

.»^« 

fti 

ii^S 

fiayx 

4S 

Raw 

28 

1,^4 

i)/ 

** 

2.5 

10.9 

63 

" 

24 

8.0 

52 

41 

8.5 

62 

Cooked     4S 

li;  ,S 

6ti''| 

1 

121  1 

1 

8.4 

per 

cen/ 

99  '.5,4,50,000 
100   0,220,0(K) 

f»!>  6,140,000 
104  : 6,910,000 
10.5  I  6,760,000 

88   0,250,000 


Controls 


Cth-  Othl  14  Oi 
6th-I2th|  12  4 
Mh-12th'  8  9 
10th-1.3th'  8  6 
"th-  9thi  11  4 
Cth-lOth:    7  8 


5.590,000 
4,499.000 
4,920,0fX); 
5,551,000 
5,1.30,000 
4,880,000, 


Food 

vaJuea  per 

kilo,  of 

body 

I    weight 


4 


0.41,  69 
0.461  75 
0.74:  69 
0.15  72 
0.40  69 
0.40  73 


9 

Raw 

108    11.4 

102 

6,020,000 

(initiiil 

12.9 

95 

period) 
6,590,000 
(final 

56* 

Cooked 

121      8.2 

100 

f)eriod) 
6,4('>O.(M)0 
(initial 

8.4 

88 

I>eriod) 
6,2.50.000 
(final 
poriod) 

•  Thi.  animal  wa,  n^^Y.st  ..-^^.,,1;^^,^;—^^—;^^^-^^^^ 

i.iiir  was  splenertnTDiErd 


82 


THE  SPLEEN  AND  AN/EMIA 


point   (see  Ta!)le  X)   a  new  series  ,.f  ol.servatic.ns  were 
luidertaken.     Six  animals  were  ])laee(i  upon  a  ealorieallv 
siiiheient  diet,  aceurately  determined,  the  onlv  difiVrenee 
I'ein^r  that  four  reeeived  raw  and  two  cooked  meat.  J«:xai  i- 
inations  of  the  blood  were  made  at  intervals  of  not  lon-er 
than  seven  days.     At  the  same  time  metabolism  studFes 
the  results  of  whiih  are  described  elsewhere,*  were  made 
on  some  (Xo.  48.  .37,  .',2,  and  .-,0)   of  the  animals.     The 
diet  m  each  of  these  experiments  consisted  of  beef-heart 
lanl,  and  su^ar,  a  small  amount  of  sodium  chloride,  and 
sufhcient  bone-ash  to  ensure  tirm  f;eees.    Details  of  nitro- 
gen content  an<l  caloric  value  of  the  foods  are  ^nven  in 
labie  X.     In  connection  with  this  table,  it  should  be  ex- 
plained that.  i„  order  to  place  the  fi^mres  coverin-  all 
animals  in  one  ^rraphic  table,  the  counts  o-iven  represent 
-veraffcs  of  several   examinations.     The   fi^-ures   before 
splenectomy  represent  the  avera^res  of  the  last  three  counts 
before  operation;  the  %ures  after  splenectomy,  the  aver- 
age of  the  three  lowest  consecutive  counts.    The  figures  for 
the  two  control  animals  represent  the  average  of  the  first 
three  and  last  three  counts  respectively. 

It  is  evident,  from  a  study  of  this  table,  that  there  is  a 
greater  tendency  for  animals  on  the  cooked  diet  to  develop 
an.-pmia  than  is  the  case  with  those  receiving  raw  meat. 
Ihus  in  the  latter  group  no  change  in  the  blood  picture 
was  evident  in  one  animal,  while  in  the  other  three  w'th 
moderate  ana?mia  the  haemoglobin  did  not  fall  below  75 
or  the  red  cells  much  below  .5,000,000.    On  the  other  hand, 
both  animals  receiving  cooked  meat  showed  a  marked 
change  in  the  blood  picture,  and  in  one  a  haemoglobin  con- 
tent^ as^ow  as  O^^JTheh^nr^^  U  relatively 

*See  page  181.  ~  " -^ 


EXl'ERIMPLXTAL  STUDIES 


ss 


greater,  as  in  all  our  previous  studies,  than  is  the  fall  in 
red  eells.     That  the  amount  of  protein  given  in  the  raw 
food  is  not  an  important  matter  is  seen  by  contrasting 
Uog  53  on  a  high  nitrogen  diet  with  Dog  50  on  a  low 
nitrogen  diet.     In  these  two  animals  the  calories  of  the 
diet  were  maintained  by  varying  the  amount  of  fat.    The 
difference  in  the  degree  of  anannia  is  negligible.     In  con- 
nection with  the  problem  of  the  influence  of  cooked  diet, 
it  is  noteworthy  that  Dog  50,  which  sensed  as  a  control 
to  52  for  four  months  before  it  was  splenectomized,  and 
was  living  all  this  time  on  a  cooked  diet,  showed  during 
this  time  a  falling  off'  in  theha>moglobin  content  of  its  bloocE 
^loreover,  this  animal  was  the  only  one  showing  a  per- 
sistent loss  of  weight  after  s})lenectomy.     Definite  con- 
'•lusions  cannot  be  drawn  from  such  a  small  number  of 
experiments,  but  the  fact  that  splenectomized  animals  on 
cooked  bee*"  develop  an  ana?mia  of  a  degree  more  closely 
approaching  that  of  animals  on  the  usual  kennel  diet, 
essentially  a  cooked  diet,  while  animals  on  a  raw  diet  have 
a  less  severe  ana-mia,  suggests  that  heat  brings  about  some 
change  in  the  diet,  which  in  the  absence  of  the  spleen  is  a 
factor  in  causing  anamia.     In  view,  however,  of  the  rela- 
tively slight  diff'erences  which  we  have  found,  experiments 
on  a  large  i.    ,il)er  of  animals  on  diverse  diets  must  be  made 
before  a  final  decision  can  be  reached  on  this  point.   Our 
views  at  present  may  be  summarized  as  follows: 

1.  The  anamia  which  develops  after  splenectomy  is 
most  marked  in  animals  on  a  mixed  "  table  scrap  "  diet  of 
meat,  bread,  cereals,  and  vegetables,  which  is  essentially  a 
cooked  diet. 

2.  Control  studies  in  which  a  unilateral  nephrectomy 
precedes  splenectomy  demonstrates  that  the  anamia  is 


84 


THE  SPLEKX  AND  ANEMIA 


not  due  to  operation,  Iicinoirlia^e,  or  accidents  of  conva- 
lescence, but  develops  only  in  the  absence  of  the  spleen. 

3.  The  results  of  studies  of  tlie  intluence  of  food  con- 
tainin-r  a  Jar^a-  amount  of  iron  in  presumably  easily  utiliza- 
hle  form,  as  in  raw  beef  spleen,  doc-s  not  support  "the  view 
that  the  ana-miu  is  due  to  lack  of  iron  in  the  focxl. 

4.  Obsen-ations  on  the  influence  of  a  diet  of  raw  meat 
as  contrasted  with  cooked  meat  show  a  more  severe  ana-mia 
in  animals  on  the  cooked  diet,  and  sunr^rest  the  possibility 
that  heat  alters  some  substance  which  the  body  cannot 
utilize  in  the  absence  of  the  spleen. 

Bi.ooD  CiiAXGKs  IX  Man  Aiter  Si'i.kxectomy 
Concerniii<r  the  influence  of  splenectomy  in  man  a 
wide  dilf'ere.ice  of  opinion  exists.  This  is  retlected  in  the 
text-books  on  hiematojooy;  for  example,  DaCosta  recoo-- 
nizes  a  diminution  of  red  cells  and  ha"mo^do})in  and  a  leuco- 
cytosis,  the  former  continuing  one  to  three  months,  the 
latter  four  to  six  weeks.  Cabot  does  not  mention  changes 
m  the  red  cells  or  ha-moglobin.  Grawitz  says  there  is"no 
especial  change  in  the  red  cells.  All  these  authors,  how- 
ever, recognize  a  lymphocytosis  and  an  eosinophilia. 

It  IS  not  difficult  to  understand  this  difference  of 
opinion.  The  spleen  is  usually  removed  for  some  acute 
traumatic  condition,  as  rupture,  or  some  chronic  sple- 
nomegaly associated  with  amvmia,  in  all  of  which  conditions 
the  blood  picture  is  altered.  Frequently,  also,  no  pre- 
liminary blood  examination  is  made,  and  if  such  examina- 
tion is  made,  observations  are  not  continued  long  after 
operation.  Under  these  conditions  it  is  not  surprising  that 
opinions  should  vaiy.  Accurate  information  concerning  the 
influence  of  the  spleen  nust  be  based  on  extirpation    for 


EXPERIMENTAL  STl  DIES 


85 


sonic  localized  lesion  which  rephices  or  aflects  only  a  small 
amount  of  the  or^ran,  does  not  alter  the  function  of  the 
remainder,  and  has  in  itself  no  influence  on  the  Wood  pic- 
ture. When  the  spleen  is  removed  under  such  conditions, 
as  in  a  simple  cyst,  or  for  misplacement,  or  for  injure- 
without  massive  hemorrhage,  the  hlood  picture  heing  nor- 
mal hefore  operation,  definite  conclusions  concerning  the 
effect  of  splenectomy  may  he  reached.  A  few  instances 
of  this  kitid  exist  in  the  literature.  For  instance.  Darling,*'" 
before  the  removal  of  a  simple  non-parasitic  cyst  of  the 
spleen,  found  the  hivmoglohin  to  he  90  per  cent,  and  the  red 
l)l(K.d-cell  count  on  two  occasions  -t,-290,00()  and  -1,7.50,000, 
respectively.  The  day  after  a  relatively  simi)le  operation, 
without  hemorrhage,  the  red  hlood-cell  count  had  dropped 
to  :j.!);i7.000,  and  three  days  after  operation  to  3.280,000. 
Three  weeks  later  the  ha>moglohin  had  returned  to  100 
per  cent,  and  the  red  hlood-cells  to  4,700,000.  Dr.  Darling 
has  heen  good  enough  to  write  us  that  three  years  after 
oi)eration  the  hlood  examination  was  as  follows:  Ha>mo- 
glohin,  100  i)ercent.;  red  hlood-cells,  5,300,000;  and  leuco- 
c>i:es,  10,000,  of  which  polymorphonuclears  form  7.5  per 
cent.,  small  lymphocytes  12  per  cent.,  large  mononuclears 
5  i)er  cent.,  and  eosinophiles  8  per  cent. 

Catellani,""  in  a  preliminary  count  hefore  extirpation  of 
a  movahle  spleen,  found  haemoglobin  70  per  cent,  and  red 
hlood-cells,  4,435,500.  One  month  after  operation  the 
ha>moglohin  had  dropped  to  00  per  cent,  and  the  red  blood- 
cells  to  3,500,000.  After  ten  weeks  the  hjcmoglobin  had 
returned  to  75  per  cent,  and  the  red  blood-cells  to  6,050,- 
000;  white  cells,  28,310.  Meyers  ^^  reports  a  child  o'f 
eleven  years  .'?plenectomized  three  days  after  an  injury 
causing  rupture  of  the  spleen.    On  the  evening  of  operation 


"  THE  SPLKKX  AM)  AX.E.MlA 

the  blootl  picture  was:  Hvd  cells,  -,,2.50  OOO-  ^vhito  r.ll 
28,000.  SVmn  tuoty-lVnu.  lu.uns  the  C^-  f'd M^' 
j|,0;«,,000,andatti.ccn,,ortwelve.,aysto;^,^^^^^^ 
l>^e„.o..loh,n  l.^ures  (Tall.vist)  offer  httle  of  value:  Gre  J 
var.a  ,o„s  ,u  the  re.l  cell  count  were  ohsen-ed  for  tl  ee 
n.o,.th.s  w.th  ^n-a,lual  in.prove.nent.  hut  not  con.plete  re  urn 
to  normal  in  that  time.  1  "-it-i<-iurn 

McCoy  ■''■■"  reports  two  cases  of  rupture,  one  of  a  nor 
mal,  the  secon.l  of  a  n.alarial  spleen.    In  the  firs  ,  on  w-h."  i 
seven  counts  were  nwule.  the  lu^no-Wohin  fell  fr  „.  70 
cer.t.   before  operation  to  20  per  cent,  three  davs  at't  r 
<.perat.on  and  steadily  rose  to  over  100  per  cent    sixteen 

3,408  000  before  o,,erat,on,  fell  to  2,300,000,  and  steadilv 
rose  to  o., 00,000.  The  patient  with  nudarial  spleen  si  , 

ha.n.o,dolHn  70  per  cent.,  red  blood  cells  4,000,000  be   ,  ■! 

dT.tdv":f't;  t ' ''"  1-  '■' '''  ^•^"*-  ^"^  -^^^«  ««^^ "-  - 

•■  4.-6,000  seven  months  later. 

In  the  case  reported  by  Matthew  and  Miles  ==-  a  count 

3  800,000  red  blood-cells  and  80  per  cent.  ha^mo^Wobin,  and 
after  two  years.  4.800,000  red  blood-cells  and  85  per  ce" 
hjemo^lobm.  '■ 

Heaton^^=  reports  a  splenectomy  for  traumatic  rupture 
>n  a  ch.ld  n,ne  years  of  a^e.    The  operation  was  done  fi" 
and  one-half  hours  after  the  injur>^  when  serious  svm  ,! 
toms  of  m  ernal  hemorrhage  had  developed.    Xo  prelinnn 
ar>'  or  early  counts  were  made-a  count  seven  davs  af  er 
operation  showed  4,100,000  red  cells  and  h^rmoc^fohin  40 

t^blToVn  r  '^"  """'^^  "'  "^'^^^"'^^  Perfect^recoverv 
the  blood  p,cture  was  4.480.000.  ha-moglobin  75  per  cent. 
The  usual  leucocytosis  was  obser%^ed. 


-I 


n 


EXI'LRIMKNT.A      STUDIES 

Fowler,'-"  a  lew  hours  after  spleiieetoiny  for  movable 
spleen,  found  the  red  eelLs  to  number  li,iH)0,(H)0  and  the 
leueoe\  tes  :U,-2()0.  Daily  eounts  thereafter  for  twenty- 
seven  days  showed  a  gradual  deerease  in  the  red  cells,  with 
a  sHo-ht  inerease  at  the  end  of  that  time  to  4,147,000,  the 
white  eells  at  the  same  time  being  12,880.  Unfortunately, 
no  blood  examination  was  made  before  operation. 

Musscr's  ''"  ease  of  cyst  of  the  spleen  illustrates  well  the 
degree  of  ana?mia  which  may  occur  and  the  long  duration 

T.\BLE  XI 

Blood   Kxamimatiovs   Before   and   AfTEu   Removal   or  the   Spleen    for 

Simple  Ciai 


Hoforo  oppration 
S  il:iys  after .... 

l.S  i];iy.>i  after.  ..  . 
!•  iiioiitlis  after.  . 

lo  iiiontlis  after. . 

'22  iiiontlis  after. . 

'J.-j  iiumtlis  after. . 

2s  nionth.'i  after. . 

•10  months  after. . 


lI»mo- 

Red  tilood 

glubin 

cells 

70 

4,3f)0,000 

yo 

4,042,000 

87 

3,1(1  ti,(XM) 

SO 

4,400,000 

(.■) 

4,220,0(X) 

/o 

2,750.000 

SO 

3,400,000 

7S 

3,400,000 

.SO 

3,0itO,O(X)i 

Leurf>- 

CJtPS 


11,400 

11,400 
13,9(H) 
17,000 
14,S0O 
12,000 
13,200 
14,800 
17,200 


of  the  .same.  The  patient  was  a  young  woman,  twenty-five 
years  of  age,  with,  for  seven  years,  a  swelling  in  the  left 
side  of  the  abdomen.  At  operation  was  found  a  large 
benign  cyst  of  the  spleen  measuring  18  cm.  in  diameter. 
The  spleen  with  cyst  wall  (after  evacuation)  weighed  400 
grammes,  so  that,  exclusive  of  the  cyst,  the  spleen  itself 
was  not  greatly  enlarged.  In  the  detailed  statement  of 
the  blood  examinations,  presented  in  Table  XI,  it  will  be 
seen  that  a  slight  anaemia  existed  before  operation. 

Staehelin^'2<^>  has  collected  from  the  literature  up  to 
1903  twenty-one  cases  of  splenectomy  following  injury 


I  Poljmor- 
!    phonu- 
j     cl»,-ara     i 


Lym- 
pho- 
cytes 


Mono- 


7,410 

8,0,-,0 

8,340 

11,950 


3,310 
1,000 
3,340 
4,250 


and 
transi-  , 
tiunala  I 


9,370  7,310 


340 
1,390 
2,220 

700 


38 


THE  SPLEEN  \SD  ANEMIA 


i    V    V  f        ;T;      "''"''  """^'^^  "^' ''''  ""--1  spleen. 
In  ^e  ^    ew  of  these  cases  was  preli.ninary  exanunatLi  of 

he  hlooc  n,ade,  and  in  only  three  instances  was  the  hlood 
^xannned  more  than  three  times,  and  usually  at  very  ir- 
regular n.tervals.  In  all  cases  there  is  evid;nce  of  some 
...rade  o    ana-nna  after  operation,  but  the  counts  were  not 

^c       a,  ,ourse  o    the  ana-nua.     The  figures  as  to  leuco- 
c\  toMs  ^-aIy  greatly. 

from  a  large  nun.her  of  reports,    uost  of  which,  because 
they  present  no  prelin.inary   counts  or  onlv   occasion! 

of  the  influence  of  splenectomy  on  the  blood  picture.   Such 
evulence  as  we  have  shows  very  distinctly  that  in  man  bo  h 

1:  X  '"r^'f '■"  '''''''''  ''^  '^'^^-  "--  than  t  e 
former,  after  splenecton.y.    Some  confusion  exists  beca.se 

of  the  .mprovement  u,  the  blood  picture  that  follows  opera- 
t.on  for  removal  of  the  enlarged  spleen  of  the  various  types 
of     sp  en.c  ana.m,a."    In  these  cases,  however,  an  abnor- 
njal  splec.  .s  ren.oved  under  abnonnal  conditions  of  t I 
blood,  and  no    a  normal  spleen  under  nonnal  conditions 
and.  as  we  w.ll  show  later,  several  factors  are  to  be  con- 
sidered m  connection  with  the  changes  in  the  blood  follow- 
'npT  removal  of  the  pathological  spleen. 

11.  INCREASED  RESISTANCE  OF  RED  BLOOD  CELLS 
Early  in  our  work  with  splenectonu/ed  anin.als  it  wis 
found  that  they  are  n.orc  resistant  to  ha>nu>lytic  p    son 
than  are  normal  animals.     This  fact  had  pre^-iously  b  en 
observed  m  the  dog  In-  Bottazzi.-^  Ranti,-  Puglie'se  an 
Luzzatt,.3.u  «,,,  .Toannovics.-  while  Domenici  '    oundt 


I 


EXPERIMENTAL  STUDIES  SO 

true  also  of  the  rabbit.    Evidence  of  the  increased  resist- 
ance was  based  on  the  fact  that  to  get  the  full  toxic  efFect 
of  a  lupniolytic  poison  it  was  necessary  to  give  a  splenecto- 
niized  dog  doses  two  or  three  times  greater  than  were  re- 
quired for  the  normal  dog.    As  a  result  of  such  observa- 
tions the  theory  was  advanced  that  the  spleen  was  concerned 
in  some  way  in  influencing  the  normal  destruction  of  aged 
anrl  effete  erv-throcytes,  and  that,  as  this  influence  was 
lost  after  splenectomy,  ha-molytic  agents  were  correspond- 
ingly less  effective.    This  was  the  basis  of  Bottazzi's  theory 
of  the  spleen  as  a  hcemocatatonistic   (i.e.,  preparing  red 
blood-cells  for  destruction)  organ,  which  'vas  later  adopted 
by  Hanti  and  supported  to  some  extent  bv  Joannovics. 
Pugliese  aiul  Luzzatti,^«^  on  the  other  hand,  denied  the 
influence  of  the  spleen,  and  pointe<l  to  the  presence,  in 
exi)erimental  anjcmia  due  to  pyrodin,  of  newly-formed  im- 
mature corpuscles,  poor  in  hjemoglobin  and  frequently 
nucleated,  which  they  thought  nnght  be  more  resistant  to 
l)yrodm  than  were  the  normal  corpuscles  and  in  this  way 
responsible  for  the  Ie;:ser  degree  of  hemolysis. 

The  first  definite  demonstration  of  a  change  in  the  red 
cells  was  made  by  Bottazzi,  who,  experimenting  on  dogs. 
fcHind  that  the  red  cells  after  splenectomy  showed  an  in- 
creased resistance  to  hemolysis  in  hypotonic  salt  solutions. 
This  increase  first  appeared  a  few  days  after  operation, 
and  mcreased  gradually  up  to  a  certain  point,  where  it 
stayed  indefinitely.  He  considered  three  possibilities: 
that  the  increased  resistance  was  due  (1)  to  the  anaemia 
following  splenectomy,  (2)  to  more  resistant  young  cells 
from  a  rapidly  proliferating  bone-marrow,  (k)  that  the 
si)lecn  has  a  special  function  to  weaken  certain  red  blood- 
cells.     From  various  controls  he  deduced  that  the  last 


I 


40 


THE  SPLEEN  .\ND  Ai;£Mf^ 


theory  was  correct,  and  upon  this  based  li-s  theory  of  the 
spleen  as  a  hiwnoeatatonistic  organ. 

At  about  the  same  time  Domeniei  '■''  showed  that  under 
smnlar  circumstances  the  erythrocytes  of  the  rabbit  pc 
sessed  an  increased  resistance.  It  is  onlv  within  the  last 
live  or  SIX  years,  however,  that  definite  measurements  of 
the  resistance  of  tlie  corpuscles  have  In^en  made  and  thereby 
the  degree  of  increased  resistance  clearly  established 

Brissaud  and  Bauer,''»  working  with  two  rabbits  and 
using  hypotonic  solutions  of  varying  strengths,  found  a 
decreased  resistance  of  the  red  cells  during  a  period  of 
eight  to  ten  days  after  splenectomy,  with,  after  this  lapse 
of  time,  a  return  to  normal  but  no  increase  in  resistance; 
they  did  not,  however,  continue  their  tests  for  periods  of 
more  than  ten  days.  Similar  negative  results  were  ob- 
tamed  by  li.agi  -'  in  dogs.  Chalier  and  Charlet,^'  testing 
both  the  rabbit  and  the  dog  by  the  salt  solution  method 
concluded  that  splenectomy  is  follov/ed  by  a  slight  increase' 
in  the  resistance  of  the  red  cells. 

„  ^^'"^^!'' ""  ^'^'>'  extensive  study,  found  as  an  average 
ot  hlty-eight  determinations  that  in  normal  dogs  the  first 
trace  of  haemolysis  occurred  in  0.42  per  cent,  salt  solution 
as  compared  with  0.35  as  the  average  for  thirty  observa- 
tions on  splenectomized  dogs;  the  average  ooncentration 
at  which  hemolysis  was  complete  was,  for  normal  .logs 
0.30  per  cent,  salt  solution,  and  for  splenectomized  dogs' 
0.23  per  cent.     Thus  in  both  series  of  observations  the 
mcreascd  resistance  of  the  splenectomized  animals  was  the 
equivalent  of  0.07  per  cent,  salt  solution.     The  difference 
may   be   expressed    in   another   way:   in   the   forty-eight 
observations  on  normal  animals  hfemolvsis  Iiegan   in  all 
except  one  test  in  solutions  of  0.48  to  0.40  per  cent.,  while 


EXPERIMENTAL  STUDIES  41 

of  thirty  obsen-ations  on  splenectoniized  animals,  in  all 
I)ut  two  it  began  in  solutions  of  0.38  to  0.30  per  cent.    The 
lesistance  of  the  red  cells  was  found  to  increase  gradually 
and  to  reach  its  maximum  at  the  end  of  about  two  months ; 
after  further  lapse  of  time  up  to  two  years  and  four  months' 
there  was  no  tendency  to  return  to  normal.    Pel  makes  a 
general  statement  concerning  the  influence  of  the  serum, 
to  tlie  effect  that  the  serum  of  a  splenectomized  dog  added 
to  the  red  cells  of  a  normal  dog  does  not  increase  the  re- 
sistance of  the  latter  to  hypotonic  salt  solution,  and,  vice 
versa,  that  the  addition  of  normal  serum  to  the  red  cells 
of  a  splenectomized  dog  does  not  decrease  their  resistance. 
IJlood    counts  showed  a  slight  decrease  in   the  number 
of  red  cells  after  splenectomy,  but  not  enough,  in  the 
opmion  of  Pel,  in  view  also  of  only  slight  changes  in  the 
percentage  of  h.-vmoglobin,  to  indicate  a  relation  to  the 
increased  resistance  of  the  red  cells.     As   for  the   fac- 
tors responsible  for  the  increased  resistance.  Pel  offers  no 
explanation. 

Ver>'  recently  Gates  "'  has  demonstrated  that  the  red 
blood-cells  of  splenectomized  animals  are  more  resistant 
than  are  those  of  nonnal  animals  when  submitted  to  the 
mechanical  damage  of  long-continued  shaking. 

The  increased  resistance  of  splenectomized  animals  to 
blood  poisons  we  observed  early  in  our  work  with  hemoly- 
tic senim,""  and  as  a  result  of  occasional  tests  with  hypo- 
tonic solutions  of  sodium  chloride  we  reached  the  tentative 
conclusion  that  it  was  due,  in  part  at  least,  to  increased 
resistance  of  the  red  cells.  This  supposition  we  confirmed 
in  a  special  study,'"'  in  which  the  cells  were  tested  not  only 
ngainst  various  strengths  of  salt  solution  but  by  the  accii- 
rate  methmls  of  immunology  against  specific  hsemolytic 


4^ 


THE  SPLEEN  AND  ANAEMIA 


serum,  with  also  investigation  of  possible  antihaemolj-tic 
action  of  the  serum  and  changes  in  complement  content. 

In  these  tests  six  dogs  were  usetl.  One  had  been 
splenectomized  ten  days,  a  second  thirty  days,  and  a  third 
four  months  before.  As  the  last  animal  had  been  given  a 
specific  hftmolytic  immune  serum  two  months  before,  thus 
introducing  a  new  factor,  the  observations  on  it  were  con- 
trolled by  a  fourth  dog  not  splenectomized,  which  had  been 
given  ha'molytic  serum  five  weeks  l)efore.  Two  normal 
dogs  were  used  as  general  controls. 

Tests  ^Vith  Varying  Gkadks  or  IIypoioxic  S.vlt 

Solution 
Chemically  pure  sodium  chloride  was  dried  for  two 
hours  at  170"  C.  and  immediately  weighed  in  amounts 
necessary  to  make  500  cubic  centimetre  volumes  of  salt 
solution,  ranging  from  0,1  to  0.5  per  cent,  in  steps  of  0.025 
per  cent.  In  order  to  be  sure  of  approximately  the  same 
volume  of  corpuscles  in  the  anaemic  as  in  the  normal  bloods, 
the  gently  defibrinated  blood  was  centrifuged  and  the 
serum  drawn  off.  One-tenth  of  a  cubic  centimetre  of  the 
corpuscular  mass  was  measured  accurately  in  a  graduated 
pipette  and  placed  in  three  cubic  centimetres  of  each  of 
the  various  salt  solutions.  Standard  colorimetric  scales 
for  comparison  were  made  by  laking  red  cells  with  distilled 
water;  thus  the  hiking  of  0.4  of  a  cubic  centimetre  of  the 
corpuscular  mass  in  twelve  cubic  centimetres  of  distilled 
water  represented  a  standard  of  100  per  cent,  haemolysis. 
Dilutions  of  this  solution  were  made  so  as  to  have  tubes 
showing  the  color  values  of  80,  fiO,  40  and  20  per  cent, 
ha'molysis.  Less  than  20  per  cent,  haemolysis  was  con- 
sidered as  a  trace  of  ha;molvsis.     In  most  instances  this 


EXPERIMENTAL  STUDIES 


43 


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Corpuscles  of 


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44 


THE  SPLEEN  .\ND  ANEMIA 


scale  was  entirely  satisfactory,  but  occasionally,  althouL^h 
a  tube  showed  100  per  cent.  ha:.molvsis  colorinietrically 
tlure  was,  on  shakin-  a  slight  macroscopic  sediment  of 
incompletely  hivmolyzed  corpuscles;  this  result  was  indi- 
cated by  a  minus  si^m  after  the  approximate  percentaffc 
of  ha-molysis.  Upon  adding  the  corpuscles  to  the  salt 
solution,  a  preliminary  readin-  was  made  and  the  mixtures 
were  placed  in  the  refrigerator.  The  final  readings  were 
made  at  the  end  of  eighteen  hours.  The  results  are  shown 
in  lable  XII, 

It  will  be  seen  that  the  blood  of  the  normal  do^s  (.30 
and  53)  shows  haemolysis  in  fairly  hi^h  percentages  of 
salt  solution,  but  that  the  resistance,  both  maximum  and 
n.m.mum,  is  increased  in  all  the  splenectomized  animals. 

inV-'l  r'    ^'      ?^  f '  '  ■'^P'-^^^^t^n^i^ed  animal,  shows 
initial  ha>molysrs  m  the  same  percentage  of  salt  solution 
as  normal  dog  53.  but  inspection  will  show  that,  whereas 
in  the  normal  dog  haemolysis  is  complete  at  0.350  per  cent 
;t  IS  not  complete  in  dog  46  until  0.300  per  cent,  is  reached' 

l^rrr,  I"  "",^""^*  *'"''  '^'  '^"^  "f  '^"^  24,  the  animal 
which  had  been  longest  splenectomize<l,  show  the  greatest 
degree  of  resistance.  That  this  resistance  is  due  for  the 
mos  part,  if  not  entirely,  to  splenectomy  is,  in  yiew  of 
results  with  bloods  30  and  53,  most  probable.  On  the 
o  her  hand  it  is  eyident,  as  shown  by  the  experience  with 
blood  43  that  m  a  non-splenectomized  animal  the  adminis- 
tration of  a  ha-molytic  Immune  serum  is  capable  of  causing 
after  a  considerable  interval,  an  increased  resistance  of 
the  red  cells. 


EXPERIMENTAL  STUDIES 


45 


Tests  With  H.t.molytic  Immune  Serum 
In  order  to  determine  the  resistance  of  the  corpuscles 
to  a  specific  hjcinolytic  iuuniuie  seruin,  the  following  tech- 
nique was  employed:  The  corpuscles  were  washed  three 
times  in  0.85  per  cent,  salt  solution,  and  blood  suspensions 
were  made  of  5  per  cent,  of  red  cells  as  contained  in  the 
centrifuf?ed  corpuscular  mass.  The  latter  rather  than 
whole  blood  was  used  l)ecause  the  use  of  whole  blood 
would  be  fallacious  in  the  case  of  ana?mic  animals.  The 
immune  serum  was  titrated  against  normal  corpuscles, 
guinea-pig  complement  was  used  in  doses  of  0,1  of  a  cubic 
centimetre,  and  the  experiment  arranged  as  indicated  in 
Table  XIII. 

Technical  limitations  prevent,  in  this  experiment,  as 
close  an  estimation  of  resistance  as  is  possible  with  hypo- 
tonic salt  solution,  but  it  can  be  seen  readily  that,  whereas 
dilutions  of  1/20  and  1/50  produce  complete  haemolysis 
of  normal  c.  puscles,  the  corpuscles  of  the  abnormal  ani- 
mals were  resistant  to  these  dilutions.  That  the  corpuscles 
of  dog  24,  which  had  been  splenectomized  four  months 
previously,  were  most  resistant  is  shown  by  the  fact  that 
whereas  partial  ha?molysis  appeared  in  all  other  corpuscles 
in  dilutions  of  1/250  and  1/300,  the  corpuscles  of  this 
dog  completely  resisted  haemolysis  at  such  dilutions.  The 
results  with  the  blood  of  dog  43  demonstrate  again  that 
the  admini3tration  of  a  ha?mol\i:ic  serum  increases  the  re- 
sistance of  the  red  cells,  irrespective  of  splenectomy. 

The  results  with  washed  corpuscles  in  these  experi- 
nionts  would  indicate  that  the  increase  in  resistance  is  a 
pioperty  of  the  corpuscles  themselves,  and  not  the  result 
of  antih.Tmolytic  power  of  the  serum,  but,  to  prove  this 


THE  SPLEEN  XSD  .iN.EMIA 


X   = 


<  =  £ 


o     o 


i,     c. 


£<     ft. 


JO  suoisuadens  opsndjoo  pansB/v^ 


EXPERIMENTAL  STUDIES 


47 


absolutely,  other  tests  were  made.  These  showed  con- 
clusively that  the  increased  resistance  in  splenectomized 
animals  is  not  due  to  changes  in  complement  value  or 
increased  antiha-molytic  power  of  the  serum.  The  latter 
point  is  brought  out  in  the  following  table,  in  connection 
with  which  it  must  l)e  pointed  out  that,  as  shown  by  Kars- 
ner  and  Pearce^""  in  another  place,  normal  dog  serum 
has  an  antiluvmolytic  property  in  a  homologous  hscmolytic 
system.  This,  however,  is  not  increased  in  the  splenecto- 
mized animal. 

It  is  seen  that  in  all  the  dilutions  of  dog  serum  used 
tlie  action  of  one  dose  of  amboceptor  and  of  complement 
was  hindered,  but  in  none  of  the  dilutions  was  the  anti- 
Iia'iiiolytic  property  sufficient  to  hinder  the  action  of  two 
doses  of  complement  and  of  amboceptor.  Weaker  dilu- 
tions were  not  considered  necessary,  because  it  seems  cer- 
tain that  between  the  action  of  a  dilution  of  1/64  on 
one  dose  of  ha-molysin  and  of  whole  serum  on  two  doses 
no  tine  gradation  could  exist. 

Tests  With  Sapontx 
In  a  third  series  of  experiments  we  have  investigated 
the  resistance  of  the  red  cells  to  saponin.  This  was  done 
because  of  the  objection  raised  by  McNeil  -"^  that  resist- 
ance tests  with  hypotonic  salt  solution  give  results  differ- 
ent from  those  obtained  when  the  washed  cells  are  tested 
with  saponin.  By  immersing  the  cells  in  hypotonic  salt 
solution,  thereby  introducing  a  complicating  factor,  he 
found  that  their  subsequent  resistance  to  hypotonic  solu- 
tions was  changed,  but  not  their  resistance  to  saponin. 
lie  concludes  that  saponin  tests  the  resistance  of  the  cell 


48 


THE  SPLEEN  .\.\D  .VN.EMU 


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EXPERIMENT.VL  STUDIES  40 

<'nvelope  and  liypotouic  salt  solution  tests  the  concen- 
tration of  salts  inside  the  cell,  a  condition  that,  according 
to  him,  is  not  affected  in  disease. 

Our  methods  have  heen  as  follows: 
Saponin  (Merck's  Saponin  Purum)  was  prepared  in 
normal  salt  solution  (0.85  per  cent.)  in  st'-en^hs  (varj'ing 
I)y  0.0025  gni.)  from  0.005  to  0.030  guis.  per  litre.  As 
all  the  tests  were  performed  and  completetl  during  a  period 
of  a  few  days,  the  factor  of  deterioration  of  the  solution 
was  avoided.  In  every  case  hlood  was  drawn  from  a 
vein  hy  means  of  a  syringe  and  the  red  cells  washed  tliree 
times  in  normal  salt  solution.  One-tenth  cubic  centimetre 
of  a  50  per  cent,  suspension  of  such  cells  was  added  to  11 
tubes  of  graded  strengths  of  saponin  solution  and  the 
•n mount  in  each  made  up  to  2  c.c.  with  normal  salt  solution. 
To  a  parallel  series  of  11  tubes  of  hypotonic  salt  solution 
varying  in  concentration  from  0.25  per  cent.  NaCl  to  0.55 
per  cent.  NaCl  equal  amounts  of  the  washed  red  blood- 
cells  were  added,  and  both  saponin  and  salt  solution  series 
were  incubated  for  two  hours  at  37.5°  C,  with  occasional 
gentle  agitation.  At  the  end  of  two  hours  the  different 
degrees  of  haemolysis  were  determined.  In  each  series  sev- 
eral tubes  in  the  middle  showed  partial  haemolysis,  with 
complete  hemolysis  at  one  extreme  and  none  at  the  other; 
so  that  accurate  comparison  could  be  made  without  resort- 
ing to  the  enumerative  method  employed  by  McNeil. 

By  this  method  it  was  found  that  the  red  cells  of  sple- 
nectomized  animals  exhibit  the  same  increase  in  resistance 
to  saponin  ha^olysis  that  was  observed  in  the  experiments 
with  hypotonic  salt  solutions  and  haemoh'tic  immune  serum. 
Comparative  tests  using  hypotonic  salt  solution  showed 


I 


50 


THE  SI'LEKN  ASD  .VN/EMIA 


that  the  dmnges,  hoth  in  niaxiinal  and  minimal  resistance, 
were  the  same  as  were  obtained  with  saponin. 

These  studies  on  the  resistance  of  red  l)lood-cclls  eon- 
firm  the  results  of  others  who  have  used  ^yraded  hypotonia 
salt  solutions  as  a  means  of  measuring  the  resistance  of 
red  cells  and  odd  new  facts  concerning  the  degree  of  resist- 
ance to  specific  ha'molytic  immune  senim  and  to  saponin. 
The  second  group  of  experiments  indicates,  as  far  as  it 
is  possible,  by  immunological  methods,  that  the  increased 
resistance  is  a  property  of  the  red  cells  themselves,  and 
not  the  result  of  increased  antihiemolytic  power  of  the 
serum. 

Since  these  observations  were  made,  Kolmer  "^  h^g 
demonstrated  that  the  erythrocytes  of  splenectomized  dogs 
show  an  increased  resistance  also  to  hjemolysis  by  cobra 
venom.  This  increased  resistance  was  observed  as  early 
as  four  days  after  splenectomy  and  usually  persisted  for  a 
period  of  about  three  weeks,  when  the  resistance  gradually 
decreased  to  the  normal  or  slightly  beyond.  His  control 
experiments  show,  moreover,  that  the  temporary  character 
of  this  increase  in  resistance  is  f)eculiar  to  venom  and 
differs  from  the  increased  resistance  to  hypotonic  salt  solu- 
tions which  persists  for  long  periods  of  time.  The  in- 
creased resistance  to  hypotonic  salt  was  constantly  jiresent 
in  all  the  dogs  he  teste<l. 

To  what  is  this  increased  resistance  due?  That  it  is  a 
concomitant  of  the  ansemia  following  splenectomy  and 
occurs  also  in  many  amemias  without  splenectomy  is  gen- 
erally admitted.  It  is  but  natural,  therefore,  that  some 
investigators  should  ascribe  the  increased  resistance  to  the 
presence  in  the  blood  of  a  large  number  of  newly-formed 
red  blood-cells,  generally  supposed  to  be  more  "resistant 


■     W.-Z<=' 


EXl'ERIMENTAL  STUDIES 


n 


than  the  mature  forms.  This  view,  as  we  have  seen,  was 
first  put  forth  by  Pugliese  and  Luzzatti  (1900)  and  has 
e()iisidtr:il)le  support.  Our  own  experience  leads  us  to 
htlieve  that  the  increased  resistance  is  closely  related  to 
the  ariii'inia,  or  to  the  process  of  repair  that  accompanies 
the  atuemia;  hut,  on  the  other  hand,  we  '  ave  not  found 
th;it  the  an.Tniia  of  splenectomy  is  characterizes!  by  the 
presence  in  the  blood  of  cells  of  immature  type  as  nucleated 
crlls,  or  by  an  appreciable  increase  in  the  so-called  reticu- 
l.iled  f)r  skeined  cell,  which  are  now  considered  as  recently 
formed  of  young  cells. 

W'e  have  examined  many  animals  for  these  cells  at 
I)eriods  raiying  from  four  days  to  one  year  after  splenec- 
tomy,"'"  but  have  failed,  as  a  rule,  to  find  an  appreciable 
increase,  and  never  more  than  2  per  cent.  Aloreover, 
Pepper  and  Peet  =>"  have  found  that  in  experimental 
ananiia  (in  the  rabbit)  due  to  phenylhydrazine  these  ceils 
are  no  more  resistant  to  h.-em^lysis  by  hypotonic  salt  solu- 
tion than  are  normal  red  cells.  It  has  therefore  l)een 
impossible  for  us  to  bring  forth  definite  evidence  that  this 
increased  resistance  of  the  cells  after  splenectomy  is  due 
to  the  presence  of  young  forms.  On  the  other  hand,  in 
view  of  the  fact  that  this  phenomenon  is  present  in  ana?niia 
in  animals  with  intact  spleen,  we  are  not  prepared  to 
eliminate  an.-vmia  entirely  as  a  factor.  Banti,^"  however, 
denies  the  influence  of  anaemia.  He  argues  that  (1)  the 
degree  of  increase  in  resistance  is  not  proportional  to 
tlic  aniemia,  (2)  it  may  develop  m  the  absence  of  anawia, 
(-i)  It  may  persist  for  many  years,  and  (4)  that  red  cells 
in  the  splenic  vein  are  less  resistant  than  those  in  the  gen- 
eral circulation.  He  rJso  makes  the  point  (5)  that  after 
the  mjection  of  h.-^molytic  serum,  in  spite  of  the  marked 


8St 


THE  SPLEEN  AND  ANEMIA 


anemia  and  the  many  young  cells  in  the  circulation,  the 
resistance  to  this  poison  is  decreased,  not  increased. 
Our  opinion  on  these  points  is  as  follows: 
1.  Although  we  believe  that  the  increased  resistance 
is  closely  associated  with  the  amernia  and  may  probably  be 
due  to  some  factor  accompanying  it  or  the  initial  regenera- 
tive processes  in  the  blood,  we  have  not  committed  our- 
selves absolutely  to  this  view,  as  Banti  seems  to  think  we 
have,  for  the  reason  that  we  have  never  been  able  to  obtain 
satisfactory  proof  on  this  point.  We  do  not,  however, 
consider  Banti's  objection  to  be  very  substantial,  for, 
although  it  is  (juite  true  that  the  degree  of  ana-mia  arising 
in  a  splenectomized  animal  is  not  always  proportional  to 
the  increase  in  resistance,  there  is  no  reason  to  assume  that 
there  should  be  a  proportional  relation. 

2.  Banti's  observations  concerning  increased  resistance 
in  the  absence  of  ana?mia  are  not  conclus"\e.     We  have 
never  f-iiled  to  find  a  decrease  of  red  cells  and  'ia«moglobin 
at  some  time  after  splenectomy;  this  may  come  early  or 
may  be  late,  but  in  our  experience  it  never  fails,  and, 
though  as  a  rule  long  continued,  may  be  slight  and  evan- 
escent.    It  may.  however,  easily  be  missed  if  continued 
counts  art  not  made  at  frequent  intervals  for  long  periods 
of  time.     In  Banti's  experiments  ihe  four  anin.als  that 
faded  to  develop  anaemia,  but  did  show  increased  resist- 
ance, Mere  examined  on  (1 )  the  second  and  twenty-fourth 
(2)  the  third  and  thirteenth.  (3)  the  third  and  fifteenth' 
and  (4)  the  fifth  and  twenty-seventh  days,  respectively 
Our  experience  has  shown  that  in  dogs  on  special  diets 
the  change  m  the  blood  may  be  long  delayed  or  may  be 
present  m  slight  evanescent  form  in  the  interval  periods 
On  the  other  hand  in  some  dogs  we  have  found  occasion- 


EXPERIMENTAL  STUDIES 


58 


■ 


all}-  -  slight  increase  of  resistance  before  the  frank  fall 
in  the  number  of  red  cells,  but,  as  it  coincided  with  or  was 
(,uickly  followed  by  a  decrease  in  hemoglobin,  we  could 
not  rule  out  the  influence  of  tiie  factors  causing  ana?mia. 

3.  Sc  also,  the  observation  concerning  increased  resist- 
ance in  man  eight  years  after  splenectomy  is  inconclusive, 
for  Banti's  blood  examination  shows  4,950,000  red  cells 
and  70  per  cent,  hemoglobin,  a  figure  for  hemoglobin,  of 
doubtful  interpretation.  Much  more  work,  both  experi- 
mental i.nd  clinical,  must  be  done  before  we  can  reach  a 
definite  conclusion  concerning  the  points  here  discussed. 

4.  The  observations  concerning  the  lessened  resist- 
ance of  cells  in  the  splenic  vein  are  offered  in  support  of 
Banti's  theory*  of  the  spleen  as  an  organ  concerned  in 
hemolysis.  While  we  believe  the  spleen  is  concerned  in 
the  destruction  of  rer'  cells,  our  observaMons  do  i  t  confirm 
the  experii  :ts  put  forth  by  Banti  to  prove  the  decreased 
resistance  of  cells  of  tl-  splenic  vein  blood.  This  will  be 
discussed  elsewhere,t  as  will  also,  in  that  it  brings  in  a 
new  factor,  the  matter  of  (5)  decreased  resistance  of  red 
cells  immediately  after  the  injection  of  a  hemolytic  serum. 

Although  we  offer  these  statements  to  support  the 
possibility  of  an  association  between  anemia  and  increased 
resistance,  we  do  so  without  presenting  definite  proof 
Moreover,  we  do  not  b-se  this  support,  though  Banti  seems 
to  think  we  do,  on  the  presence  of  young  cells  in  the  blood 


Based  on  Bottazz.  s  theory  that  the  spleen  has  special   (h«mo- 

oataton.sfc)  action  upon  red  blood-<-ells  as  they  pass  thro,      .  the  organ 

and  as  a  result  of  whieh  they  became  less  resistant.     T       absence  of 

he  spleen    according  to  this  theory,  does  away  with  th.s  action,  and 

the  red  cells    therefore  are  mere  resistant  in  splenectomized  animals 

T  see  page  87. 


54 


THE  SPLEEN  AND  AN.EMIA 


The  skeined  cells  we  have  shown  are  no  more  resistant  than 
are  the  mature  cells.  We  do  think,  however,  that  it  is 
some  factor  intimately  associated  with  the  causation  or 
repair  of  the  ana?mia  followint^  splenectomy,  and  not  the 
mere  ahsence  of  the  spleen,  that  is  responsible  for  the  in- 
creased resistance,  and  that  this  factor  is  operative  in  other 
ana'mias,  in  the  presence  of  the  spleen.  That  this  factor 
may  be  entirely  independent  of  the  anaimia  we  willingly 
admit. 

III.    LESSENED  TENDENCY  OF  HEMOLYTIC  AGENTS 
TO  CAUSE  H-ffiMOGLOBINURIA  AND  JAUNDICE 

AFTER  SPLENECTOMY 
In  the  preceding  section  we  have  presented  the  evidence 
concerning  the  increased  resistance  of  the  erythrocytes 
as  determined  by  the  behavior  of  these  cells  to  various 
lytic  agents.  In  the  present  section  we  offer  the  evidence 
concerning  the  closely  related  phenomenon — the  lessened 
tendency  to  haemoglobinuria  and  icterus — exhibited  by 
splenectomized  dogs.  To  establish  this  point  we  have  ex- 
amined tlie  urine  for  Iitemoglobin  and  bile-pigment^"' 
^'"  and  determined  the  changes  in  the  blood  as  shown  by 
red-cell  counts  and  haemoglobin  estimations.''"'  The 
hjemolytic  agent  used  in  every  instance  has  been  hasmo- 
lytic  immune  scrmn.* 

Female  dogs  were  used  almost  exclusively  in  order 
that  the  tests  for  ha-inoglobin  and  bile  might  be  made  on 
urine  obtained  by  catheterization.  All  operations  were 
under  ether  ana-sthesia.  as  were  also  the  injections  of  serum. 

*  Rabbits  were  injeetcd  five  times  with  five  to  ten  cubic  centimetres 
of  dog's  blood  nt  intervals  of  five  to  seven  days  and  bled  about  one 
week  after  the  last  injection. 


^^^0t.c^^;kt^^  .:^^^^^.i^ 


EXPERIMENTAL  STUDIES 


55 


Tlie  injections  were  either  into  a  small  vein  of  the  leg  or 
into  the  jugular  vein.  Each  experinant  on  a  splenecto- 
niized  animal  was  controlled  hy  the  injection  of  a  normal 
animal  with  the  same  serum.  When  the  animals  were  of 
approximately  the  same  weight  they  received  the  same 
amounts  of  serum ;  but  when  the  weight  varied  more  than 
half  a  kilo  they  received,  with  a  few  exceptions,  corre- 
sponding doses  per  kilo,  of  body  weight. 

The  urine  of  all  animals  was  examined  for  coagulable 
protein,  haemoglobin,  and  bile  pigment.  For  the  diagnosis 
of  jaundice,  the  appearance  of  bile-pigment  in  the  urine 
has  been  deemed  sufficient.  Table  XV  shows  the  effect 
of  a  weak  lutmolytic  serum,  administered  three  days  after 
splenectomy. 

TABLE  XV 

Effect  of  H>«molytic  Serum  Administered  Three  Dats  After  Splenec- 
tomy, With  Control 


Date 


Dec.  11,  1911 
Dr.-.  14,  1911 

Dec.  15,  1911 

Doc.  10,  1911 

Dec.  17,  1911 
Doc.  18,  1911 
Dec.  19,  1911 


Dec.  20,  1911 
We.  21-22, 

1911 
Dec.  23,  1911 


Dog  U.    Weight  10,000  gm. 


Dog  13.    Weight  8,990  gm. 


Splenectomy 

Urine  normal;  2.5  c.c. 

lytic  serum  in  vein 
Urine  normal 


lucmo- 


Uriiie  normal;  4.5  c.c.  of  same 
serum  in  vein 

Trace  of  albumin;  no  bile,  no 

lia-moglobin 
Trace  of  albumin;  no  bile,  no 

hirraoglobin 
Trace  of  albumin;  no  bile,  no 

hiTUioglobin 
Ligation  of  common  bile  duct 

under  ether  anaesthesia 
Hile-pigmenta  in  urine 

Bile-pigmentain  urine  incrra.''inB 
Rile-pi({ment8  in  urine  increasing 
Killed  by  chlorofonn 


Control 

Urine  normal;  2.5  c.c.  haemo- 
lytic  serum  in  vein 

Bile  test  positive;  no  hemo- 
globin, no  albumin 

Bile  test  positive-  no  tueroo- 
globin,  no  albmnm;  4.5  c.c.  of 
same  serum  in  vein 

Bile  test  positive;  albumin  pres- 
ent, no  Wmoglobin 

Bile  test  positive;  albumin  pres- 
ent, no  Wmoglobin 

Bile  test  positive;  albumin  pres- 
ent, no  Wmoglobin 

Died,  under  ether,  during  oper- 
tion  to  remove  spleen 


I 


56 


THE  SPLEEN  AND  ANEMIA 


In  this  experiment  the  hemolytic  serum  was  not  power- 
ful enough  to  cause  a  destruction  of  blood  of  sufficient 
grade  to  produce  ha?moglobinuria,  although  it  did  cause 
in  the  control  animal  enough  destruction  to  produce  jaun- 
dice; on  the  other  hand,  the  splenectomized  animal  was 
free  from  jaundice. 

The  objection  might  be  raised,  in  connection  with  this 
experiment,  that  the  jaundice  of  the  control  animal  might 
be  due  to  the  fact  that,  as  the  smaller  of  the  two  animals, 
it  received  a  relatively  larger  dose  of  serum.  This  objec- 
tion is  not  tenable,  as  is  shown  by  Table  XVT.  In  the 
experiment  here  presented,  a  stronger  serum  was  used  and 
the  amount  injected  was  adjusted  to  the  weight  of  the 
animals. 


TABLE  XVI 

Effect  of  Hemolytic  Serum  Six  Dats  After  Splenectomy,  With 

Control 


Date 


Dec.  14,  1911 
D?c.  20,  i'JU 

Dec.  21,  1911 

Dec.  22,  1911 

Dec.  23,  1911 

Dec.  24,  1911 

Dec.  25,  1911 

Dec.  26-27, 

1911 
Dec.  2S,  1911 
Dec.  29,  1911 


Dog  3.     Weight  n,4(X)  gm. 


Splenectomy 

Urine  nnnnal 

0.5  c.c  scrum  per  kilo. 

ILEmoglobinuria;  no  bile-pig- 
ment 

HiEmog'.ohinuria;  no  bile-pig- 
ment 

Hipmoglobinuria;  no  bile-pig- 
ment 

Trace  of  hspmoglobinuria;  no 
bile-pigment 

No  hspmoglobinuiia;  :o  bile- 
pigment 

Faint  trace  of  bile-pigment 
No  liile-pigmcnt 
No  bile-pigment 


Uo(r  7.    Weight  10,5.S0  gm. 


Control 

Urine  normal 

0.5  c.c.  serum  per  kilo. 

Hscmoglobinuria;  marked  jaun- 
dice 

Haenioglobinuria;  marked  jaun- 
dice 

No  haemoglobinuria;  marked 
jaundice 

No  hiemoglobinuria;  marked 
jaundice 

No  hemoglobinuria;  marked 
jaundice 

Much  hile-pigment  in  urine 
Much  bile-pigment  in  urine 
Much  bile-pigment  in  urine 


t?g4,, 


k'Jim 


EXPERIMENTAL  STUDIES 


67 


That  the  same  results  are  obtained  after  longer  periods 
of  time  have  elapsed  is  shown  in  Table  XVII,  which  pre- 
sents the  results  obtained  sixty-five  days  after  splenectomy. 


TABLE  X\1I 
Decreased  Tendency  to  Jaundice  StxTT-rrvE  Days  Ajteb  Splenectomy 


Date 


Dog  in.     Weight  9,720  gm. 


Dec.  9,  1911 
Fel).  12,  1912 
Feb.  13,  1912 
Feb.  14,  1912 


Feb.  15,  1912 
Feb.  16,  1912 

Feb.  17,  1912 
Fob.  18,  1912 
Fel).  19,  1912 


Feb.  20-21, 
1912 


ISplenectoray 
L'rine  normal 

0.25  c.c.  serum  per  kilo,  into  vein 
Urine   free   from    bienioglobin 
and  biio-pigment 

1  c.c.  same  serum  per  kilo,  into 
vein 

No  haemoglobin  uria;  no  bile- 
pigment 

No  hajmoglobinuria;  no  bile- 
pigment 

2  c.c  per  kilo,  of  and  !ier  scrum 
into  vein 

Ha:>mogIol)inuria;  faint  trace  of 

bile-pigment 
No  hsemoglobinuria ;  faint  trace 

of  bile  (?) 
No  hemoglobinuria;  faint  trace 

of  bile  (?) 
Ojmmon  bile-duct  ligat«d 
Large  amount  of  bile-pigment 

in  the  urine 
Chloroformed 


Dog  22     Weight  6,710  gm. 


Control 

Urine  normal 

0.25  c.c.  serum  per  kilo,  into  vein 

No  hjjumoglobinuria;  bile-pig- 
ments present 

1  c.c.  per  kilo,  of  same  serum  into 
vein 

Marked  hsemoglobinuria;  much 
bile-pigment 

No  hsemoglobinuria;  much  bile- 
pigment 

No  third  injection.  Spleen  ex- 
cised 

Well  marked  bile  reaction 

Well  marked  bile  reaction 
Well  marked  bile  reaction 

Well  marked  bile  reaction 
Chloroformed 


In  all  of  these  experiments  the  splenectomized  dogs 
sliow  less  tendency  to  jaundice  and  usually  to  hsemoglo- 
binuria than  do  the  normal  dogs  with  corresponding  doses 
of  the  .same  hemolytic  serum,  and  this,  as  will  be  shown 
liiftr.  we  have  found  to  be  characteristic  of  animals  that 
have  ])een  splenectomized  for  various  periods  up  to  one 
year.    Beyond  that  period  we  have  made  no  observations. 


CHAPTER  III 

CONCERNING  THE  SUPPOSED  REGULATORY  INFLUENCE 

OF  THE  SPLEEN  IN  BLOOD  DESTRUCTION 

AND  REGENERATION 

A.  IN  RELATION  TO  THE  DECREASED  TENDENCY 
TO  HEMOGLOBINURIA  AND  JAUNDICE:  (1)  THE 
RELATION  OF  SPLEEN  TO  THE  LIVER  AND  THE 
FORMATION  OF  BILE  FROM  H-ffiMOGLOBIN.  (2) 
THE  INFLUENCE  OF  THE  COURSE  OF  THE  BLOOD 
TO  THE  LIVER.  (3)  THE  INFLUENCE  OF  ANiEMIA. 
(4)  THE  INFLUENCE  OF  THE  INCREASED  RESIST- 
ANCE OF  THE  RED  CELLS.  (5)  ARE  SPLENIC  EX- 
TRACTS H-EMOLYTIC?  (6)  POSSIBLE  INFLUENCE 
OF  FATTY  ACIDS  AND  LIPOIDS. 

In  the  preceding  chapters  have  been  presented  the 
three  most  important  phenomena — anaemia,  increased  re- 
sistance of  the  erythrocytes,  and  decreased  tendency  to 
jaundice — which  follow  splenectomy.  A  discussion  of 
these  involves  a  presentation  of  the  literature  and  of  ex- 
periments dealing  with  the  supposed  regulatory  influence 
of  the  spleen.  As  the  increased  resistance  of  the  red  cells 
has  a  relation  both  to  the  problem  of  anaemia  and  to  that 
of  the  decreased  tendency  to  jaundice,  it  will  not  be  dis- 
cussed separately,  but  in  relation  to  each  of  these. 

How  does  the  absence  of  the  spleen  influence  the  oc- 
currence of  hfemoglobinuria  and  jaundice? 

(1)  One  improbable  explanation,  that  the  absence  of 
the  spleen  prevents  the  secretion  of  bile  by  the  liver,  may 
be  dismissed  immediately,  for,  as  shown  in  Tables  XV  and 
XVII,  the  ligation  of  the  bile-duct  in  the  splenectomized 

58 


F>^.    .A*'-!-..  ^•.:-- *i^'•i<~-■ 


■•-ft^^.-ij^^ 


J 


REGULATORY  INFLUENCE  OF  THE  SPLEEN         59 

animal  ■'^''  causes  the  aijpeaiance  of  bile  in  the  urine  within 
twtnty-four  hours.  On  the  other  hand  (Table  XVII), 
the  excision  of  the  spleen  in  an  animal  with  hemolytic 
jaundice  does  not  inmiediately  lessen  the  elimination  of 
bile  through  the  urine. 

Does  the  spleen  take  part  in  the  formation  of  bile- 
pigment  from  ha>moglobin  ?  As  the  solution  of  this  prob- 
lem necessitated  the  study  of  h{emoglobin?emia  in  normal 
animals,  we  undertook  an  extensive  investigation  "'^*  under 
the  following  heads:  (1)  The  degree  of  ha?moglobina?mia 
necessary  in  order  to  recognize  free  htemoglobin  in  the 
serum;  (2)  the  degree  of  hjEmoglobinaemia  necessary  for 
the  escape  of  hemoglobin  through  the  kidneys:  (3)  the 
percentage  of  hfemoglobin  eliminated  by  the  kidneys;  (4) 
the  degree  of  retention  of  ha?moglobin  necessary  to  cause 
jaundice;  (5)  the  influence  of  the  absence  of  the  spleen  on 
the  elimination  or  retention  of  hjemoglobin  and  the  occur- 
rence of  jaundice. 

Methods 
Defibrinated  dog  blood  was  hsemolyzed  with  distilled 
water,  sodium  chloride  was  added  to  render  the  solution 
isotonic  with  dog  blood,  the  hwmolyzed  blood  was  centrifu- 
galized  to  remove  the  stroma,  and  the  haemoglobin  content 
was  then  determined  with  a  Fleischl  hsmoglobinometer. 
Definite  amounts  of  the  haemoglobin  solution,  always 
freshly  prepared,  were  allowed  to  flow  from  a  burette  into 
a  small  branch  of  the  femoral  vein.  The  first  appearance 
of  haemoglobin  in  the  urine  was  determined  by  a  catheter 
in  the  bladder  or  by  a  catheter  in  one  ureter.  In  order 
to  aid  the  flow  of  urine,  each  dog  received  300  cubic 
centimetres  of  water  by  stomach-tube.  From  time  to  time 
the  skin  was  punctured  and  blood  was  drawn  into  capillary 


00 


THE  SPLEEN  AND  AN^MU 


-.-* 


tubes  to  deteniiine  how  early  free  htemoglobin  appeared 
in  the  serum. 

The  elimination  of  h.-emoglobin  in  the  urine  was  esti- 
mated by  rendering  the  urine  acid  with  hydrochloric  acid 
to  about  X/10  and  comparing  this  solution  of  acid  ha?ma- 
tin,  suitably  diluted,  with  a  1  per  cent,  solution  made 
according  to  the  Sahli  method  from  blood  containing  100 
per  cent,  of  hfemoglobin  by  the  Fleischl  scale.  A  Dubosc 
colorimeter  was  used  for  making  the  comparison. 

The  quantities  of  hemoglobin  are  designated  in  the 
table  (Table  XVIII)  in  grammes,  calculated  on  the 
assumption,  for  the  sake  of  convenience,  that  blood  giving 
a  reading  of  100  per  cent,  by  the  Fleischl  scale  contains 
14  per  cent,  of  hemoglobin.  This  figure  is,  of  course,  only 
approximately  correct,  but,  as  only  relative  quantities  are 
of  importance  in  this  work,  an  approximate  detertnination 
of  the  absolute  quantities  of  hemoglobin  is  sufficient. 

In  order  to  determine  quantitatively  the  amount  of 
hemoglobin  which  must  be  retained  in  order  to  cause  jaun- 
dice, decreasing  amounts  of  hemolyzed  blood  were  injected 
intravenously  into  a  series  of  normal  dogs;  in  each  case 
the  percentage  elimination  by  the  kidney  and  occurrence 
or  non-occurrence  of  bile-pigment  in  the  urine  were  noted. 

The  results  of  these  experiments  are  shown  in  Experi- 
ments I  to  IX  in  Table  XVIII. 

It  is  seen  (Experiments  II,  VT,  VII,  VIII,  IX)  that 
the  retention  of  0.39  gramme  of  hemoglobin  per  kilo, 
caused  marked  choluria;  of  0.23  gramme,  slight  choluria 
for  twenty-four  hours;  and  of  0.22  gramme,  a  very  faint 
choluria  for  eight  hours;  the  retention  of  0.18  and  0.19 
gramme  per  kilo,  of  body  weight  failed  to  cause  choluria. 

The  ,  ercentage  of  hemoglobin  eliminated  by  the  kid- 


^m^-:i 


REGULATORY  INFLUENCE  OF  THE  SPLEEN    61 


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ney  appears  to  be  a  variable  quantity.  Thus,  in  Experi- 
ment \'l,  3-2.5  per  cent,  of  the  hii-nioglobin  injeeted  was 
eliminated  by  the  kidney;  in  Experiment  VI 1,  2G.8  per 
cent.;  in  ExiKiiment  Vlll,  17.1  per  cent.;  in  Experiment 
IX,  35.9  per  cent. 

In  these  four  experiments  the  haemoglobin  solution 
was  rapidly  injected  during  a  period  of  from  four  to  thir- 
teen minutes.  When  the  solution  was  introduced  more 
slowly  a  much  larger  amount  could  apparently  l)e  cared 
for  in  the  liver  witliout  the  production  of  jaundice.  Thus, 
if  we  refer  again  to  Table  XVII  I,  Experiment  I,  in  which 
the  solution  was  introduced  at  intervals  throughout  a 
period  of  «ft\-six  minutes,  we  find  that  an  amount  of 
hemoglobin  was  retained  equal  to  0.33  gramme  per  kilo., 
without  bile-pigments  occurring  in  the  urine. 

These  experiments  seem  definitely  to  establish  the 
mechanism  by  which  free  ha?moglobin  is  removed  from  the 
blood-serum  under  normal  conditions.  Our  conception  of 
this  mechanism  is  as  follows:  The  kidney  does  not  elim- 
inate hicmoglobin  until  its  concentration  in  the  blood-serum 
reaches  a  certain  level.  This  concentration,  we  conclude 
from  Experiments  I,  II,  III,  is  about  that  produced  by 
the  j)resence  of  0.06  gramme  of  free  hirnioglobin  per  kilo, 
of  body  weight.  As  soon  as  the  concentration  of  the  hfpmo- 
globin  in  the  serum  is  above  this  point,  the  h.-pmoglobm 
passes  through  tlie  kidneys  and  we  have  ha>moglobinuria, 
but  as  soon  as  it  falls  below  this  amount,  the  haMiioglobln- 
uria  ceases.  However,  other  tissues,  of  which  presumably 
the  liver  is  the  most  important,  appear  to  take  up  hemo- 
globin as  soon  as  mere  traces  are  present  in  the  serum, 
and  continue  to  remove  it  from  the  serum,  whether  the 
renal  threshold  is  exceeded  or  not.     Tlierefore,  whenever 


91^: 


mM;^'' 


REGLXATORY  INFLUENCE  OF  THE  SPLEEN         63 

the  kidney  is  removing  hemoglobin  from  the  serum,  these 
other  tissues  are  also  removing  it.  Under  the  conditions 
of  these  experiments  the  kidneys  removed  17  to  36  per 
tent.,  and  tlie  liver  (and  other  tissues r)  04,  to  83  per  cent. 

The  hicmoglobin  which  the  liver  removes  is  changed 
into  bile-pigment,  which,  if  it  is  not  produced  in  too  large 
amounts,  or  if  the  hicmoglobin  is  not  taken  to  the  liver  too 
rapidly,  passes  out  as  bile-pigment  in  the  usual  manner 
through  the  bile-passages.  On  the  other  hand,  if  the  luemo- 
globin  is  taken  up  by  the  liver  in  larger  quantities,  and 
especially  if  this  occurs  rapidly,  the  bile-pigment  is  formed 
faster  than  the  bile  capillaries  can  remove  it,  and  it  is  re- 
absorbed into  the  circulation  and  appears  in  the  urine. 

The  effect  of  splenectomy  on  this  process  was  deter- 
nimed  in  part  by  observations  on  the  same  animal  before 
and  after  splenectomy,  and  in  part  on  animals  splenecto- 
mized  for  various  lengths  of  time  (Table  XVIII.  j:xperi- 
ments  X  to  XV) . 

These  six  experiments  on  splenectomized  animals,  in 
all  of  which  bile-pigments  appeared  in  the  urine  for  a 
short  time  and  in  small  quantities  after  the  retention  of 
0.44,  0.31,  0.25,  0.28.  0.26,  and  0.22  gm.  per  kilo.,  re- 
spectively, indicate  that  the  threshold  for  jaundice  in 
splenectomized  dogs  is  approximately  0.22  gramme  per 
kilo.,  the  same  as  in  the  experiments  (VI  to  IX)  with 
normal  dogs,  in  which  the  threshold  was  found  to  be  be- 
tween 0.18  and  0.22  gramme  per  kilo. 

When  we  examine  the  percentage  of  ha?moglobin  elim- 
inate! by  the  kidneys  in  the  six  splenectomized  animals, 
we  find  that  it  runs  a  trJle  lower  than  the  limits  deter- 
mined for  normal  animals,  being  18.8,  16.8.  21.1.  27..5,  7.2 
( ?) ,  and  1 8.4  per  cent,  (average,  excluding  the  fifth  fi^re^ 


•*ij; 


64 


THE  SPLEEN  AND  AN.EMIA 


20.5  per  cent.),  as  compared  with  32.5,  26.8,  17.1,  35.9, 
16,  and  26.5  per  cent.  (Experiments  VI  to  XI),  with 
an  average  of  25.8  per  cent.  This  difference  is,  however, 
so  slight  that  we  can  conclude  that  splenectomy  has  no 
influence  in  increasing  the  elimination  of  free  haemoglobin 
by  the  kidneys,  nor  dots  it,  as  is  shown  by  the  occurrence 
of  choluria  in  each  of  the  experiments,  influence  the  ability 
of  the  liver  to  form  bile-pigments  from  haemoglobin,  or 
interfere  with  the  elimination  of  these  pigments.  Thus 
one  of  the  possible  explanations  for  the  failure  of  jaundice 
to  follow  the  administration  of  a  ha?molytic  serum  in  sple- 
nectomized  animals  is  shown  to  be  untenable. 

(2)    The  Influence  of  the  Course  of  the  Blood  to 

the  i.iaer 

Although  the  experiments  described  in  the  preceding 
section  led  to  negative  conclusions,  there  is  another  possible 
factor,  a  purely  mechanical  one;  that  is,  the  relation  of  the 
spleen  to  the  blood  supply  of  the  liver.  Inasmuch  as  the 
spleen  is  undoubtedly  a  seat  of  destruction  of  red  cells,  the 
splenic  blood  must  carry  to  the  liver  haemoglobin  in  larger 
an.  )unts,  or  more  concentrated,  than  does  the  blood  reach- 
ing the  liver  through  the  hepatic  artery  in  the  absence  of 
the  spleen.  This  difference  in  haemoglobin  content,  under 
the  conditions  mentioned,  might  be  suiRcient  to  explain,  in 
a  purely  mechanical  way,  the  lessened  tendency  to  jaun- 
dice after  removal  of  the  spleen.  This  possibility  was 
investigated  in  two  groups  of  experiments :  in  one  ^^  haemo- 
globin was  injected  in  the  general  circulation  (femoral 
vein)  and  into  portal  circulation  (mesenteric  vein),  and 
the  influence  of  these  two  procedures  on  the  occurrence  c' 
hsemoglobinuria  and  jaundice  was  studied.    In  another  '*• 


m 


REGULATORY  INFLUENCE  OF  THE  SPLEEN 


65 


set  of  experiments  the  blood  from  the  spleen  was  diverted 
from  the  liver  by  ligation  of  the  splenic  vein,  as  well  as  by 
an  Eck  fistula  or  an  anastomosis  of  the  splenir  vein  with 
the  vena  cava,  and  the  occurrence,  under  these  '  jnditions, 
of  jaundice  due  to  the  administration  of  htemolytic  agents 
was  studied. 

In  connection  with  this  problem  it  may  be  recalled  that 
Pontick^**    applied    the    term    "  spodogenous "    (anoSoc 
waste  products)  to  the  spleen  of  hemolysis,  swollen  in  con- 
st(iuence  of  the  accunmlation  of  disintegrating  erythro- 
cytes, and  that  he  noted  that  simultaneously  the  liver  elim- 
inates a  bile  very  rich  in  pigment,  and  suggested  that  this 
latter  is  derived  from  the  lia?moglobin  set  free  in  the  spleen, 
carried  by  the  portal  circulation  to  the  liver,  and  removed 
by  this  organ.    Ponfick  further  expressed  the  view,  based 
on  experiments  not  quoted  in  detail,  that  the  liver  could 
completely  remove  and  transform  into  bile-pigment  liber- 
ated haemoglobin  up  to  the  extent  of  one-sixtieth  of  the 
total  haemoglobin  of  the  body,  but  that  hwmoglobin  set 
free  in  excess  of  this  amount  passes  through  the  liver  and 
is  eliminated  by  the  kidneys,  causing    hsemoglobinuria. 
One-sixtieth  of  the  total  haemoglobin  in  the  dog  is  about 
0.1 8  gm.  per  kilo.    In  the  preceding  section  we  have  shown 
that  the  injection  of  0.14  to  0.85  gm.  per  kilo,  of  hsemo- 
glohin  as  laked  blood  will  cause  the  appearance  of  hemo- 
globinuria, but  that  a  factor  of  great  importance,  appar- 
ently overlooked  by  Ponfick,  is  the  rate  at  which  the  hemo- 
globin is  liberated  in  the  circulation.    The  more  slowly  it 
is  introduced  the  larger  is  the  quantity  that  the  liver  can 
take  up  without  permitting  the  concentration  in  the  blood 
to  reach  at  any  time  that  required  for  the  production  of 
hemoglobinuria.    Also,  we  have  shown  that,  while  small 


'--'':<;  ^'-^-iL 


•»  THE  SPLEEN  AND  ANEMIA 

amounts  of  injected  hsnioglobin  are  removed  by  the  liver 
and  presmuably  excreted  as  bile-pi^ients  in  the  bile  with- 
out the  occurrence  of  jaundice,  if  the  injected  hemoglobin 
be  in  excess  of  0.30  to  0.40  gm.  per  kilo,  the  liver  i .  unable 
to  eliminate  all  the  bile-pigment  formed  from  the  excess 
of  haemoglobin,  and  some  of  the  bile-pigment  is  reabsorbed 
from  the  liver  and  under  these  circumstances  appears  in 
the  urine.    It  was  noted  in  this  respect,  also,  that  the  rate 
of  injection  is  of  greater  importance  in  determining  the 
amount  of  ha?nioglobin  that  the  liver  will  tolerate  without 
the  appearance  of  bile-pigments  in  the  urine.    Very  slow 
but    long-continued    acniiinistration   of    hemoglobin    can 
eventually  overtax  the  hepatic  excretory  power  and  lead 
to  the  appearance  of  bile-pigments  in  the  urine,  although 
the    hiemoglobin    transformation    may    have    been    slow 
enough  to  jjerniit  of  its  continued  adecjuate  removal  from 
the  circulation  by  the  liver  with  at  no  time  the  development 
of  ha?moglobinuria.     Thus  the  first  effect  of  haemoglobin 
liberation  into  the  blood  is  an  increased  bile  pigment  con- 
tent of  the  bile.    This  was  shown  experimentally  by  T,.r- 
chanoff'.*-"    I  f  the  amount  of  ha'moglobin  be  small  enough 
and  its  liberation  slow  enough,  this  is  the  only  efFect.     A 
slightly  larger  amount,   rapidly   liberated,  wnll   produce 
hemoglobinuria.    A  still  laiger  amount,  extremely  slowly 
liberated,  will  produce  bile  in  the  urine.    An  equal  amount 
liberated  at  an  intermediate  rate  may  produce  both  hemo- 
globinuria and  bile-pigments  in  the  urine. 

Following  Ponfick.  miny  other  workers  have  attribute<i 
importance  to  the  spleen  as  the  site  of  disintegratitm  of 
erythrwytes;  among  these  may  lie  mentioned  Hunter."*" 
Gabbi.""  and  Mya.'"='  Bottazzi,''"'  ni  his  studies  of  the 
blood  after  splenectomy,  noted  an  increased  resistance  of 


FEGULATORY  INFLUENCE  OF  THE  SPLEEN    67 

the  erythrocytes  to  hypotonic  salt  solutions,  and  it  was  to 
tills  factor  that  Banti  '^  attributed  the  greater  resistance 
and  diminished  tendency  to  jaundice  of  splenectomized 
animals  receiving  hjeniolytic  agents. 

However,  Pugliese  and  Luzzatti  ^"^  did  not  agree  with 
Bottazzi,  hut,  noting,  with  Banti  and  others,  the  dimin- 
ished tendency  to  jaundice  after  splenectomy,  they  made 
furtlier  studies  along  the  lines  suggested  by  Ponfick's  ob- 
sei-ations  and  elaborated  the  following  hypothesis:    The 
sj)k'en  is  the  natural  location  for  the  disintegration  of  ery- 
throcjies  aft<?r  the  administration  of  ha?molytic  poisons, 
1111(1  the  hfumoglobin  so  liberated  is  carried  directly  by  the 
})ortal  system  to  the  liver,  there  to  be  converted  into  bile- 
piginent  and  to  l)e  excreted  in  the  bile,  or,  if  present  ii 
grtat  quantity,  to  be  reabsorbed  and  appear  in  the  urine 
and  tissues  as  bile-pigments  and  thus  produce  jaundice. 
')/i  the  other  hand,  in  the  absence  of  the  spleen,  the  Mood- 
cclls  undergo  disintegration  elsewhere,  probably  chiefly  in 
till'  bone-marrow,  as  suggested  by  JVIartinotti  and  Bar- 
hacci.-"    lifcmoglobin  liberated  in  the  bone-marrow  could, 
uiuicr  these  circumstances,  reach  the  liver  only  through  the 
general  circulation.     It  would  therefore  be  diluted  and, 
moreover,  would  reach  the  liver  largely  through  the  hepatic 
artery— a  vessel  normally  carrying  blood  for  nutritive  pur- 
poses, not  for  purposes  of  elaboration.    For  these  reasons 
it  is  to  be  expected  that,  in  the  splenectomized  animal,  the 
Iiainoglobin  would  reach  the  liver  much  more  gradually 
and  at  a  rate,  indeed,  which  might  well  lie  within  the 
capacity  of  the  liver  for  complete  excretion  as  bile-pig- 
iient,  and  hence  no  reabsorption  of  bile-pigments  would 
occur  and  jaundice  would  not  develop. 

Pugliese  and  Luzzatti  were  able  to  show  by  the  aid 


W 


THE  SPLEEi:  AND  ANEMIA 


of  a  bile  fistula  tluit,  while  the  other  constituents  of  the 
bile  are  but  little  altered  by  splenectomy,  the  bile-pigments 
are  reduced  to  about  one-half.  IVIoreover.  while  the  bile 
of  the  splenectomized  animal  shows  an  increase  in  the  bile- 
})igments  after  the  administration  of  ha^molytic  poisons, 
tliis  is  not  SvT  pronounced  as  in  the  normal  animal;  the 
increased  pigmentation  of  the  bile  is,  however,  of  longer 
duration  in  the  splenectomized  animal. 

In  order  to  test  the  hypothesis  of  Pugliese  pnd  Luz- 
zatti,  we  have  injected"-^  a  constant  amount  per  kilo,  of 
hemoglobin  solution  in  the  form  of  laked  blood  into  a  series 
of  dogs,  injecting  each  at  least  twice— once  into  the  gen- 
eral circulation  by  way  of  the  femoral  vein  and  once  into 
the  portal  circulation  by  way  of  a  mesenteric  vein.  The 
rate  of  injection  has  been  always  the  same.  In  some 
instances  the  femoral  injection  was  given  first,  in  other 
instances  the  mesenteric  At  least  five  days  were  allowed 
to  elapse  between  injections.  We  have  thus  been  able  to 
study  the  eflfect  of  the  site  of  the  injection  upon  the  develop- 
ment of  Inemoglobinuria  and  of  bile-pigments  in  tlie  urine, 
and,  from  our  results,  believe  we  may  draw  conclusions 
as  to  the  fate  of  haemoglobin  when  liberated  into  the  portal 
system,  on  the  one  hand,  or  into  the  general  circulation, 
on  the  other. 

In  these  experiments  a  fasting  normal  dog  was  bled, 
the  blood  defibrinated,  the  cells  thrown  down  by  a  centri- 
fuge, and  the  supernatant  serum  removed.  About  four 
volumes  of  distilled  water  were  then  added  to  the  cells  to 
induce  ha?n-olysis,  and  the  mixture  agitated  for  fifteen  to 
twenty  minutes.  The  solution  was  then  centrifugalized 
rapidly  for  twenty  minutes  to  remove  tlie  cell  stromata, 
was  made  isotonic  by  addition  of  sodium  chloride,  and  cen- 


REGULATORY  INFLUENCE  OF  THE  SPLEEN         69 

trifuf^aliztxl  to  remove  any  globulin  thrown  out  of  solution 
upon  adding  the  salt.     One  cubic  centimetre  of  this  solu- 
tion was  then  diluted  with  ;:;')  c.c.  of  distilled  water  and 
its  haemoglobin  strength  determined  in  a  Fleischl-Miescher 
ha-nioglobinometer.    Into  a  normal  dog  was  then  injected 
intravenously  as  much  of  this  solution  as  should  equal 
either  0.3  gm.  or  0.4  gm.  of  hsemoglobin  per  kilo,  of  body 
weight.     Injections  were  given  at  such  a  rate  that  the  en- 
tire injection  should  occupy  ^ne  minute  per  kilo,  of  body 
weight.     All  bleedings  j"  .  mjections  were  made  under 
ether  ana?sthesia.     Injections  into  the  general  circulation 
were  made  into  one  of  the  smoll  veins  of  the  leg.    Portal 
injections  were  made  by  drawing  a  loop  of  intestine  from 
the   abdomen   imder   aseptic   precautions    and    injecting 
llirough  a  needle  into  a  small  jiiesenteric  vein.     In  some 
instances  water  was  given  by  stomach-tube  at  the  close 
of  the  operation.     The  urine  was  then  collected,  the  dog 
king  kept  in  a  metabolism  cage,  and,  if  hemoglobin  ap- 
peared, the  amount  was  estimated  either  directly  in  the 
FIcischl-AIiescher  ha?moglobinometer  or  by   comparison 
with  a  standardized  acid  hsematin  solution.     In  addition, 
we  followed  thu  course  of  the  jaundice  by  observing  the 
persistence  of  bile-pigu'.ents  in  the  urine  after  ha?moglobin 
iiijeetion  into  either  the  mesenteric  or  the  femoral  vein. 
The  urine  was  examined  for  bile-pigments  by  the  Rosen- 
bach  test. 

The  results  as  regards  h.emoglobinuria  are  shown  in 
Table  XIX.  In  each  of  five  dogs  used,  the  output  of 
h;emoglohin  by  the  kidney  was  much  less  when  the  hirmo- 
globin  was  introduced  into  the  mesenteric  vein  than  when 
Introduced  into  the  femoral  vein,  and  this  is  true  regardless 
of  which  injection  was  performr.'  first.    This  we  attribute 


70 


THE  SPLEEN  AND  ANEMIA 


to  the  removal  of  the  hsEinoglobin  to  a  greater  extent  hy 
the  Hver  when  the  injection  is  made  into  a  mesenteric  vein, 
with  the  result  that  the  haemoglobin  reaching  the  general 
circulation  is  less  concentrated  and  is  less  hkely  to  be  elim- 
inated by  the  kidneys  and  appear  in  the  urine. 

TABLE  XIX 

Influence  of  Sfte  of  Injection  on  Amot-nt  of  H-emoolobin  Euminated 

IN  THE  Urine 


Hsmoglobin  injectioon 

Date 

Gm.  of  hsmoglobin  per  kilo,  elim- 

inatetl  in  the  unne  after  injection 

into 

Femoral  vein 

Meaenteric  vein 

Doff  26  (0  4  nn.  i)er  kili>.) 

Mar.  20 
Mar.  26 
Fel).  2.5 
Apr.   15 
Jan.     9 
Jan.    15 
Mar.    2 
Mar.  26 
Jan.     7 
Jan.    15 
Feb.   19 
Mar.    2 
Mar.  20 
Feb.  25 
.\pr.   lo 

0.085 

0.043 
0.024 

0.026 
0.017 

0.025 
0.014 

Dna  12  (0  3  inn.  ner  kilo.)   

0.043 
0.029 

naff    ^^  (0  3  ma.  Der  kilo.) 

Doff    3  (0  3  nn.  ner  kilo.) 

None 
None 

Splenectomized 

Trace 

Door  49  (0  3  irni.  Her  kilo.) 

None 

Three  montlis  after  splenectomy 

0.010 

The  results  of  the  study  of  the  degree  and  persistence 
of  jaundice  (a.s  indicated  by  bile-pigments  in  the  urine) 
in  the  dogs  after  the  two  types  of  injection  are  shown 
in  Table  XX. 

It  will  be  seen  that  in  the  six  dogs  studied,  the  jaundice 
was  distinctly  more  persistent  after  mesenteric  than  after 
femoral  injection,  and  this  was  true  regardless  of  which 
injection  was  made  first.  In  Dog  4  two  successive  injec- 
tions were  made  into  the  femoral  vein  to  determine  whether 
the  second  injection  would  give  a  result  notably  different 
from  the  first.     Sucli  was  not  the  c^ise,  the  duration  of 


REGULATORY  INFLULNCK  OF  THE  SPLEEN 


71 


the  bile-pigments  being  the  same  after  each  injection  when 
both  were  made  into  the  femoral  vein. 

In  our  studies  both  of  hasmoglobinuria  and  of  the  per- 
sistence of  jaundice  after  haemoglobin  injections  we  have 
employed  splenectomized  as  well  as  normal  dogs,  but  have 
found  that  the  mere  absence  of  the  spleen  has  no  influ- 
ence upon  the  fate  of  haemoglobin  injected  into  either  the 
general  or  portal  circulation.  The  place  of  injection  is 
the  important  factor. 

TABLE  XX 

Peusistence  of  Bile-Pigment  in  the  Urine  After  Ksmoolop'n  Injection 

AS  Determined  by  Point  of  Injection 


D»t« 

Pcraijtence  after  injection  into 

Hsmoglobin  iDjectiona 

Femoral  vein 

Mesenteric  vein 

dayg 

dayt 

Dog    4  fO.3  gm.  per  kilo.) 

Jan.     9 

Jan.   16 

Dog    5  (0.3  gm.  per  kilo.) 

Jan.     9 

3 

Jan.   15 

12  + 

Dog  25  (0.4  giu.  per  kilo.) 

Mar.  21 

Mar.  26 

7  + 

Dog  26  (0.4  gni.  per  kilo.) 

Mar.  20 

Mar.  26 

7  + 

Dog  12  (0.3  gm.  per  kilo.) 

Feb.  25 

5 

Apr.  15 

iJog    3  (0.3  gm.  per  kilo.) 

Jan      7 

0 

Jan.   15 

9 

Splenectomized 

Feb.  19 

Mar.    2 

4 

Mar.  20 

0 

I>uK  49  (0.3  gm.  per  kilo.) 

Feb.  25 

4 

riirce  mouths  after  splenect   rny 

Apr.  15 

6 

These  experiments  indicate,  therefore,  that  when  hsemo- 
globiii  is  set  free  in  the  portal  circulation  a  larger  amount 
i.s  held  by  the  liver  and  converted  rapidly  into  bile  )igment 
than  is  the  case  when  it  is  set  free  in  the  general  circulation, 
and  that  under  the  former  condition  overloading  of  the 
liver  with  bile-pigment  more  readily  occurs  and  jaundice 
is  more  apt  to  develop. 


7t 


THE  SPLEEN  AND  AN^MU 


This  mechanicjil  iiiHuence  must  therefore  be  a  factor, 
though  not  necessarily  the  only  factor,  in  the  lessened 
tendency  pfter  spLnectoniy  to  the  jaundice  which  follows 
blood  destruction  due  to  hfprnolytic  agents,  for  whether 
the  spleen  be  an  active  factor  in  destroying  the  erythrocytes 
or  whether  it  plays  merely  a  passive  part  as  a  place  for 
the  deposition  of  the  ('.isir»tegrating  cells,  there  can  be  no 
question  that  in  this  organ  a  large  number  of  cells  imdergo 
their  final  disintegration  after  the  action  of  ha;molytic 
poisoiis,  and  that  the  h:cmoglobin  there  liberated  passes  by 
the  portal  system  directly  to  the  liver.  When  the  spleen 
is  removed  this  disintegration  occurs  in  other  organs,  nota- 
bly in  the  lymph-nodes  and  bone-marrow,  and  the  hemo- 
globin from  these  organs  passes  not  into  the  portal  but 
into  the  general  circulation,  from  which  it  reaches  the  liver 
more  gradually  and  in  a  more  dilute  form.  Jaundice  is 
therefore  less  a{)t  to  occur  under  such  circumstances,  when 
a  ha?molytic  agent  is  administered,  than  is  the  case  in  the 
normal  animal. 

Other  experiments  giving  essentially  the  same  result 
and  supporting  the  injection  experiment  described  above 
are  those*  in  which,  by  ligation  of  the  splenic  vein  and 
blood-vessel  anastomosis,  the  splenic  blood  was  diverted 
from  the  liver  and  ha?molytic  agents  were  then  adminis- 
tered.'^"" These  showed  the  same  decreased  tendency  to 
jaundice  that  is  shown  by  splenectomized  animals. 

(3)    The  Influence  of  AN.aEMiA 

This  we  have  investigated  in  some  detail.'''"'  In  our 
earlier  work  it  was  noticed  more  or  less  accidentallv  that 


♦  Sec  p.igc  1  .SO. 


^4^::<-^^   -i^:^     jm 


REGULATORY  INFLUENCE  OF  TOE  SPLEEN 


73 


an  injection  of  haemol^'tic'  seruin  into  anaemic  (logs,  whether 
splenectoniized  or  not,  did  not  cause  jaundice  so  readily 
a^  in  dogs  with  normal  red-cell  count  and  normal  ha?mo- 
^lohin  content.  This  observation  suggested  that  it  might 
not  be  the  mere  absence  of  the  spleen,  but  secondary 
changes  in  the  blood  consequent  upon  the  absence  of  the 
spleen,  that  in  addition  to  the  mechanical  factor  prevented 
the  appearance  of  jimidice  in  splenectomized  animals. 
We  therefore  turned  our  attention  to  the  condition  of  the 
hlood  in  all  splenectomized  animals. 

As  we  have  shown  in  the  first  chapter,  splenectom\ 
is  followed  by  a  moderate  ana?mia  in  which  a  decrease  of 
lia'nioglobin  is  especially  prominent.  The  lowest  level  of 
this  anaemia  corresponds  to  the  third  to  the  sixth  week, 
and  it  occurred  to  us  that,  in  this  early  period,  the  lessened 
toiidency  to  jaundice  might  be  associated  in  some  way 
with  the  coexistent  anaemia.  Obviously  it  was  possible  to 
test  this  hypothesis  by  studying  the  effect  of  a  hicmolytic 
scrum  on  dogs  rendered  ana?mic  in  some  other  way  than 
by  splenectomy.  This  was  d.me  by  bleeding,  as  is  shown 
in  an  experiment  (see  Table  XXI)  in  which  a  normal 
(log  with  high  hemoglobin  content  is  contrasted  with  a  dog 
rendered  moderately  anemic  by  bleeding. 

In  this  experiment  the  anemic  dog,  although  it  received 
the  same  amount  of  serum,  proportionately,  and,  on  ac- 
count of  its  greater  weight,  twice  as  much,  actually,  as  the 
control,  failed  to  develop  hemoglobinuria  or  jaun(Iice,  and 
this  in  spite  of  the  fact  that  the  actual  fall  in  hemoglobin 
and  red  blood-cells  was  more  rapid  and  greater  than  in  the 
control.  Anemia  would  appear,  therefore,  to  be  an  impor- 
tant factor  in  lessening  the  tendency  to  jaundice.  How 
the  anemia  acts  to  lessen  the  jaundice  Is  not  indicated  by 


74 


THE  SPLEEN  AND  ANEMIA 


our  experimental  data.  A  possible  explanation  which  may- 
be offered,  however,  is  the  following.  VVe  have  shown  that 
the  liver  exhibits  a  saturation  point  for  haemoglobin,  so 

TABLE  XXI 
Effect  of  H^emolttic  Serum  on  a  Dog  Rendered  Anaemic  by  Bleeding. 

NoRUAL  Control 


Dat« 


AprU  18,  1912 


AprU  20,  1912 

April  21,  1912 
10  A.  M..  .  . 


April  21,  1912, 
11.10  A.  M. 


5  P.  M. 


April  22,  1912 


April  23,   24, 

2.5,  1912 
April  24,  1912 

April  2o,  1912 


Anietnic  dog 


WeiRht,  10,740  em. 
Urine:   free  of  aTl)umin 
179  c.c.  of  bioo<'  tHJven 

from  jugular  vein 
150  c.c.  of  blwKl  taken 

from  jugular  vein 

Urine:    no  albumin,  no 

bile-pigmcnt 
Blood:re(J cells, 4,450  000; 

ha-moglobinH?  [lercent. 
Fragility:  0.3 +  ;  0.4- 


Date 

April  16, 

1912 

11.45  A. 

M. 

2.45  P. 
3.15  P. 

M. 
M. 

6.30  P. 

M. 

Control  dog 


Received  0.25  c.c.  ha-mo- 

lytic  serum  per  kilo,  in 

vein 
Urine:    no  albumin,  iio 

l)i]e 
Blood  :red cells, 3,400,000;  April  17,  1912 

lucmoglobin  5-t  jx;r  cent. 

Urine:    no  haemoglobin, 

no  bile  ' 

Blood:red  cells,  3,2.50,000;! 

ha;muglobin49i)ercent.  j  April  18,  1912 


Urine:  no  bile-pigment 
Blood :  red  celk,  3,040,(K)0; 

hifriioglol  nil  42  i)cr  cent . 
Blood :  red  celLs,  2.910,000; 

lueuioglobin  42  [x^r  cent. 


April  19,  1912 


\y eight,  5,350  gm. 

Urine:  no  albumin,  no 
bile. 

Blood:  red  cells,  5,390,- 
000;  hemoglobin  107 
per  cent. 

Fragility:   0.4  +  ;  0.5-. 

Received  in  vein  0.25 
c.c.  per  kilo,  of  .same 
-serum  as  ana-niic  dog. 

r     ''h  bile  in  urine. 

Blood:  rod  cells,  5,330,- 
000;  haemoglobin  98 
ix;r  cent. 

I  rine;  contaiiis  haemo- 
globin and  much  bile 

Blood:  red  celLs,  4,660,- 
000;  hamoglobin  85 
jx'r  cent. 

Urine  contains  haemo- 
globin and  bile-pig- 
ment 

Blood,  red  cells,  4,470,- 
000;  liujmiigiobin  73 
per  cent. 

Urine:  no  haemoglobin, 
but  trace  of  bile 

Urine:  no  bile,  no  albu- 
min 

Blood:  red  cells,  4,930,- 
000 


that,  if  hicnioglohin  he  supplied  to  it  in  excess  of  a  given 
amount,  jaundice  will  result,  but  that,  conversely,  ha?mo- 
globin  supplied  to  it  in  quantities  less  than  this  amount 
will  not  give  rise  to  jaundice.     Now  it  inav  well  be  that 


■^1M 


w 


REGLLATORY  INFLUENCE  OF  THE  SPLEEN         75 

in  an  animal  rendered  anemic  either  by  bleeding  or  by 
insufficient  blood  formation  the  daily  blood-cell  destruc- 
tion may  be  less  than  in  the  normal  animal  and  hence  the 
liver  be  further  from  its  normal  saturation  point  for  hemo- 
globin.   In  such  an  animal  more  hemoglobin  could  be  liber- 


TABLE  XXII 

Effect  op  HjuioLrnc  Sebum  on  Sple.nectomized  Dooa  with  Normal  Red 

Ckll  Count 


Diite 


Ajiril  17,  1912 
April  21,  1912 

il.25A.  M. 
5.20  P.  M. 


April  22,  1912 


April  23,  1912 
April  24,  1912 


Four  day  splenertomy 


Date 


W  eight,  7,8S0  gm. 
Splenectomy 
Uriiie :  no  albumin,  no  bile 
Blo<jd :  red  cells,  5,880, 000; 
heemoglobin  102  percent. 
Fragility:  0.3  +  ;  0.45- 
Received  in  vein  0.25  c.c. 

serum  per  kilo. 
Urine :  (by  catheter)  con- 
tains large  amount  of 
bile-pigment  and  faint 
trace  of  albumin  I 

Blood  .red  cells,  5,330,000; 
hemoglobin  93  percent,  j 
L'rine:  trace  of  bile  i 

Blood:  red  cells,  6,260,000; 
hsEmoglobin  81  per  cent . 
l'rine :  faint  trace  of  bile  ' 
Urine :  no  albumin,  no  bile 
Blood  :red  cells,  4,800,000; 
hn'inoglobin  70  iier  cent. 


Feb.  10,  1912 
AprU  10,  1912 


12  M. 

2.45  P.  M. 
3.50  P.M. 

11.00  P.M. 
April  17,  1912 


Sixty-six  day  aplenectomy 


April  25, 1912  Blood rredcells, 4,510,000;  April  18, 1912 
hffii  oglobinSOpcrcent. 

April  19,  1912 


Splenectomy 
Weight,  12,680  gm. 
Urine:     faint  trace  of 

albumin,  no  bile 
Blood:  red  cells,  5,230,- 

000;    ha-moglobin    83 

rier  cent. 
Fragility :  0.25  + ;  0.35- 
Received  in  vein  0.25 

c.c.  serum  per  kilo. 
Urine :  trace  of  bile-pig- 
ment 
Blood:  red  cells,  5,3 10,- 

000;    ha?mog!obin    84 

per  cent. 
Urine:  moderate amoun 

of  bile-pigment 
Urine :  moderate  amount 

of  bile-pigment 
Blood:  red  cells,  4,830,- 

000;    hemoglobin    79 

per  cent. 
Urine:  no  bile-pigment. 
Blood :  reil  cells,  4,500,- 

000 
Urine:  no  bile. 


ated  into  the  circulation  as  the  result  of  a  single  insult  and 
I>e  removed  by  the  liver  without  exceeding  the  saturation 
point  of  the  liver  and  thus  jaundice  would  not  occur. 

^t  is  therefore  at  once  evident  that  if  it  is  the  piosence 
"f  an  anaemia,  subsequent  to  the  splenectomy,  which  is  of 


T6 


THE  SPLEEN  AND  A\.EML\ 


importance  in  preventing  the  development  of  jaundice, 
then  ha'moiytie  serum  administered  to  an  animal  soon  after 
splenectomy,  before  anjemia  has  developed,  or  long  after 
splenectomy,  when  the  blood  has  again  returned  to  normal, 
should  induce  the  appearance  of  the  bile-pigments  in  the 
urine.  Both  these  experiments  were  performed  and  the 
results  tabulated  in  Table  XXIT. 

In  both  of  these  splenectomized  animals  bile-pigments 
appeared  in  the  urine,  and  a  trifle  more  abundantly  in  that 
animal  which  at  the  beginning  had  the  higher  bamoglobin 
and  red  blood-cell  count.  Thus  anaemia  would  appear  also 
to  be  a  factor  in  lessening  the  tendency  to  jaundice  after 
administration  of  a  h^emolytic  agent. 

(4)    Ini-xuence  of  thk  Ixcrk.\sed  Resistance  of  the 

Red  Cells 
In  neither  of  the  splenectomized  animals  in  Table 
XXII  was  the  jaundice  quite  so  marked  as  in  the  control 
animal  given  the  same  dose  of  the  same  serum  (see  Table 
XXI),  and  in  neither  did  the  ha^moglobinuria  occur  that 
was  observed  in  the  control.  The  rate  of  fall  of  ha?moglo- 
bin  and  red  blood-cells  in  these  animals  shows  that  the  rate 
of  blood  destruction  in  the  control  animal  was  much  greater 
than  in  either  of  the  splenectomized  animals.  In  the  ani- 
mal splenectomized  four  days  the  eventual  blood  destruc- 
tion equalled  that  of  the  control,  but  it  occurred  nmch  more 
slowly;  and  in  that  splenectomized  for  sixty-six  days  the 
amount  of  blood  destruction  was  relati\-ely  slight.  This 
ccmstitute  a  peculiarity  in  the  reaction  of  a  splenectomized 
dog  to  ha?molytic  agents  which  necessitates  detailed  dis- 
cussion.   The  splenectfmiized  animal  may  show  an  eventual 


I 


REGLL.\TORV  INFLUENCE  OF  THE  SPLEEN         77 

blood  destruction,  following  ha-niolytic  agents,  less  than, 
LqwA  to,  or  greater  than,  the  controls,  but  almost  always 
the  rate  of  blood  destruction  is  slower.  We  believe  that 
at  least  one  factor  although  not  the  only  one,  in  this  phe- 
nomenon is  the  influence  of  the  increased  resistance  of  the 
red  blood-cells.  In  confirmation  of  this  it  may  be  noted 
that  in  the  three  animals  under  discussion  the  rate  of  blood 
destruction  was  proportionate  to  the  fragility  of  the  red 
blood-cells.  Such  increased  resistance  of  the  red  blood- 
cells  has  been  shown  to  be  characteristic  of  all  splenecto- 
mized  dogs.  Consideration  of  the  results  obtained  upon 
introduction  of  free  hfemoglobin  into  the  circulation  at 
various  rates  indicates  at  once  the  importance  of  a  slower 
rate  of  blood  destruction  which  must  lead  to  a  diminished 
tendency  both  to  hfemoglobinuria  and  to  jaundice.  Hence 
the  increased  resistance  of  the  red  blood-cells,  in  that  it 
causes  a  slower  rate  of  blood  destruction  after  administra- 
tion of  hcTmolytic  agents,  is  r  third  factor  to  be  considered 
in  any  attempt  to  explain  the  lessened  tendency  in  these 
animals  to  hajmoglobinuria  and  jaundice. 

Ana-mia  is,  of  course,  no  longer  operative  in  animals 
splenectomized  for  long  periods  of  time  in  which  the  blood 
picture  has  returned  to  normal.  In  such  the  increased 
resistance  of  the  red  cells,  which"  persists  indefinitely — our 
longest  observation  covers  twenty  months — must  be  a 
factor  which  cooperates  with  the  mechanical  factor  pre- 
viously discussed  to  limit  the  degree  of  jaundice.  In  such 
animals  a  faint  trace  of  jaundice — never  as  much  as  in 
the  control  animal — is  not  unusual. 

This  persistence  of  the  lessened  tendency  to  jaundice 
one  year  after  splenectomy  is  shown  in  the  following  table: 


MICROCOPY    RESOLUTION   TEST    CHART 

ANSI  and  ISO  TEST  CHART  No    2 


1.0 


I.I 


150     *== 

m 


1^ 
I- 


||2j> 
12.2 

zo 

1.8 


1.25 


1.4 


-^  -APPLIED  INA/IGE     Inc 

="  1653   Eas'    Mam    Si'eel 

p^  Rochester.    Ne<»    fo'k         U609        USA 

-^  (716)    482  -  0300  -  Phone 

=.■=  (716)  288  -  5989  -  Fo« 


78 


THE  SPLEEN  AND  AX.EMIA 


TABLE  XXIIl 

Effect  of  Hemolytic  Sebum  One  Year  After  Splenectomy,  With 

CoNxaoL 


Time 


One  yeur  after  aplenectumy 
(dog  42; 


Before    injei--    Weight,  6,400  gm. 

Urine ;  no  albumin,  no  bile 


Ist  in      'inn 

Alter  iiijtction 
1-3  days 

3  days 
2d  injectidii 

4  dj\s 
6  days 

6  davs 


Received  in  vein  0.5  c.c. 

serum  i)cr  kilo. 
Urine:  trace  of  albumin ; 

faint  trace  of  bile 

Received  in  vein  1  c.c.  of 

same  Fcruin  i)er  kilo 
Marked  luumoiiloliiiiuria 
Faint     hicmonlDbinuria; 

doubtful  bile  te,«t 
Fiiint     h;cinoglol)inuriri; 

faint  but  detiiiite  bile 

test 
Died.      No   evidence   of 

jaundice  at  autop.sy 


Time 


Before  injeo- 
tion 

1st  injection 

.\ft or  injection 

1  dav 

2-3  days 

3  days 
'2d  injection 

4  (lays 
o  days 

0  days 


'  days 


Control  (dog  43) 

Weight,  0,61.")  gm. 
Urine:    no  albiuiiin,  no 

bile 
Received  same  dose  of 

same  senini  as  dog  42 
Urine:  trace  of  albumin; 

well  marked  bile  test 
I'rine:   no  bile 
Received  ,'iame  dose  of 

same  senirn  a.s  dog  42 
Marked  lixmoglobinuria 
Moderate   ha'moglobin- 

uria;  marked  bile  test 
Faint    luemoplobinuria; 

large  amount  of  bile 

Urine:  no  hamoglobin; 
deeply  bile-stained 

Chloroformed.  At  au- 
to] )sy  general  bile 
staining  of  tissues 


AVe  may  ct)nclude,  therefore,  that  three  factors  are 
concerned  in  the  decrea.'^ed  tendency'  to  jaundice  when 
hii'inolytic  ajjfents  are  a(hninistered  to  splenectoniized  ani- 
mals. The  most  important  is  the  mechanical  factor,  the 
disturbance  of  the  spleen — liver  circulation;  the  second, 
always  present,  is  the  increased  resistance  of  the  red  cells. 
These  two  factor.,  apjjarently  always  work  together.  A 
third  possible  factor,  not  always  clearly  demonstrable,  is 
that  of  anivmia. 


{,'))      II.KMOLVTU'   POWKR   OF   Spi.EXIC   EXTRACTS 

The  histologic  evidence  of  the  destruction  of  erythro- 
cytes by  phagocytic  cells  of  the  spleen  has  naturally  sug- 
gested the  possibility  of  the  liberation  by  the,  e  cells  of  a 


REGULATORY  INFLUENCE  OF  THE  SPLEEN 


79 


ferment  capable  of  acting  extracellularly.  If  it  could  be 
demonstrated  that  such  a  free  ha?niolysin  is  present  in  the 
si)leen  we  would  have  at  once  an  adequate  explanation  of 
the  decreased  tendency  to  jaundice  in  the  splenectoniized 
animal,  for  with  the  spleen  absent  fewer  red  cells  would  be 
destfv)yed  and  less  hcCnio<?lobin  sent  to  the  liver  for  the 
elaboration  of  bile-pigmetit.  As  this  hypothesis  has  been 
made  the  basis  for  splenectomy  in  ha'molytic  ana?mias,  we 
liave  gone  into  this  question  in  some  detail.  The  literature 
of  the  subject  shows  tliat  during  the  past  few  years  several 
investigators  have  tested  the  influence  of  such  spleen  ex- 
tracts upon  red  cells.  The  methods  employed,  based  on 
the  technique  of  Korschun  and  Morgenroth,--'*  are  very 
similar,  but  the  results  obtained  have  been  very  contra- 
dictory. Korschun  und  ^lorgenroth  found  in  several  or- 
gans a  hipmolytic  substance  of  unknown  origin,  coctostabile 
and  soluble  in  alcohol,  which  did  not  arise  from  constituents 
of  the  blood-serum  and  was  in  no  way  peculiar  to  the  spleen. 
Xolf,""  on  the  other  hand,  found  that  the  h;emolytic  power 
of  splenic  extract  was  distinctly  greater  than  that  of  the 
liver,  mesenteric  lymph-nodes,  or  kidneys,  but  only  slightly 
more  than  that  of  the  lung.  This  haMuolytic  substance  was 
specific  for  the  species  and  was  destroyed  at  lOu"^  C. 
Achard.  Foix,  and  Salin,^  repeating  these  experiments, 
showed  that  the  final  solution  was  strongly  acid,  presuma- 
bly as  the  result  of  bacterial  action,  and  that  control  tests 
made  with  precaution  as  to  asepsis  were  uniforndy  nega- 
tive. Widal,  Abrami,  and  Brule.^"'''  in  similar  experiments, 
could  get  no  lucmolysis  with  fresh  extracts  used  on  the  day 
tliey  were  prepared;  sometimes,  also,  extracts  24  to  48 
hours  old  were  without  effect.  From  these  results  they 
conclude  that  the  ha?molvtic  substance  is  not  a  true  h.Tmo- 


80 


THE  SPLEEN  AND  AN/EMIA 


lysin,  but  the  prrxluct  of  cell  autolysis.     Iscoveseo  and 
Zacchiri  ''■"'  have  shown  that  after  placing  the  mixture  of 
pulp  and  saline  solution  in  the  thermostat  for  fifteen  to 
twenty  hours  the  filtered  extract,  on  the  addition  of  red 
cells  and  after  standing  two  and  one-half  hours  in  the  ther- 
mostat, exhibits  2.5  per  cent,  to  8  per  cent,  bemolysis,  as 
determined  by  the  Dubosc  colorimeter,  and  conclude  that 
the  h.Tmolytic  power  of  splenic  extracts  is  unimportant. 
Weill  *'''*  found  a  weakly  ha?molytic  substance  in  extract 
of  spleen  that  was  inactivated  at  50°  and  reactivated  with 
guinea-pig  serum.    This  was  more  powerful  than  a  lymph- 
node  extract  prepared  in  the  samr  way,  but  much  less 
powerful  than  the  extract  obtained  from  the  spleen  by  long 
maceration.     The  latter  was  not  destroyed  below  80°  C, 
and  its  action  was  hindered  by  adding  fresh  serum.    Ex- 
tracts fiom  lymph-aodes  prepared  in  the  same  way  showed 
only  slight  lucmolytic  action,  and  those  from  other  organs 
were  negative.     Banti ""  and  Furno  '^^  state  that  fresh 
extracts  of  the  normal  spleen  sometimes  have  no  hicmolytic 
action  and  sometimes  a  weak  action  which  is  increased  on 
standing  24  to  48  hours  on  ice  and  is  not  destroyed  by 
heating  to  00°  or  even  100°.     They  consider  it  a  cyto- 
haemolysin,  normally  present  in  the  spleen  in  small  amounts 
and  much  increased  after  the  administration  of  hsemolytic 
agents.    Thus  we  find  that  Nolf.  Weill,  Banti,  and  Furno 
find  splenic  extracts  to  have  a  ha?molytic  action  greater 
than  that  of  other  organs.    Achard,  Foix  and  Salin,  and 
Widal,  Ahrami  and  Brule,  on  the  other  hand,  fail  to  find 
any  hfcniolytic  action  of  the  fresh  extract,  and  think  It 
occiu-s  only  after  autolysis  or  bacterial  decomposition  of 
the  spleen. 

Our  experiments  were  made  with  extracts  from  the 


REGIXATORY  INFLUENCE  OF  THE  SPLn^EN 


81 


spleens  of  three  dogs.     The  tet-luiique  described  by  Xolf 
was  followed  in  the  main,  with  several  additio  !s  in  the  way 
of  control  experiments.     On  washing  through  the  aorta 
it  was  found  that  the  technique  which  will  give  a  blood-free 
kidney  or  liver  will  not  render  the  spleen  bloodless.  Various 
expedients  were  tried,  therefore,  to  secure  a  ha?moglobin- 
f ree  extract.    It  was  found  that  if  the  spleen,  after  washing 
through  the  aorta,  was  cut  in  small  pieces  and  pounded 
with  a  ptstle  against  a  wire-meshed  sieve  placed  in  a 
mortar,  with  the  aid  of  frequent  washings  with  salt  solu- 
tion, a  blood-free  white  mass  was  obtained  consisting  partly 
of  reticulum  and  partly  of  adherent  splenic  pulp.      (In 
Table  XXIV  this  is  called  "Extract  A.")     As  it  was 
possible  that  the  haemolytic  substance  might  not  be  re- 
tained, or  in  only  small  amounts,  in  this  fraction,  extracts 
were  also  made  from  that  part  of  the  spleen  that  was 
mashed  through  the  sieve.     This  residue  was,  of  course, 
distinctly  blood  tinged,  so  that  it  was  necessary,  in  order 
ti)  remove  the  blood,  to  mix  it  with  distilled  water,  centri- 
fuge, discard  the  supernatant  fluid,  and  repeat  the  process 
until  colorless  tissues  were  obtained.     (In  Table  XXIV 
this  is  termed  "  Extract  B.")     In  each  case  the  material 
thus  obtained  was  mixed  with  double  the  amount  of  salt 
solution  and  placed  in  the  refrigerator.    Tests  were  always 
made  with  extracts  one  or  two  hours  old — a  small  portion 
being  filtered  off  for  this  purpose — and  in  two  instances 
also  after  eighteen  and  twenty-four  hours.    Control  tests 
were  made  in  one  experiment  with  extracts  of  liver  and 
mesenteric  lymph-nodes.    As  it  was  possible  to  wash  these 
organs  free  of  blood  before  removal  from  the  body,  extracts 
were  easily  obtained  by  grinding  the  tissues  in  sand  with 
mortar  and  pestle  and  placing  them  as  before  in  the  ice- 


-^^■ 


g2  THE  SPLEEN  AND  ANEMIA 

chest  with  double  the  amount  of  salt  solution.  In  two 
experiments  the  tests  were  made  on  the  corpuscles  of  the 
animal  furnishing  the  spleen;  in  one  the  corpuscles  of 
another  dog  was  used  without  a  difference  in  result.  The 
preparation  of  the  washed  red  blood-corpuscles,  the  dilu- 
tions, incubation,  and  so  forth,  were  according  to  Nolf's 
technique.  Each  tube  contained  0.1  c.c.  of  washed  dog's 
corpuscles  with  varying  amounts  of  splenic  extract  made 
up  to  2  c.c.  with  normal  salt  solution.  Controls  were  made 
with  normal  salt  solution  and  distilled  water.  The  results 
are  presented  in  Table  XXIV. 

TABLE  xxrv 

The  HiEMOLrnc  Powsr  of  Extracts  of  Spleen  and  Other  OROArre 


Chanoter  of  eitrmct 


1.  Dog  1. 


Fresh    epleen    ex- 
tract A  . 


Amount  of  splenic  extract  in  c.c. 


1.95      1.5       1.0       0.5       0.3        0.2       0.1      0.05 


2.  Dog  2.    Fresh    spleen    ex- 

tract A 

3.  Same.    Extract  B 

4.  Same.    After  extraction  in 

ice  chest  for  24  hours   . 
6.  Dog  3.     Fresh     spleen    ex 
tract  A 

6.  Spleen  extract  A  after  ex- 

traction in  Ice  chest  for 
24  hours  .....    .    • ■ 

7.  Fresh  spleen  extract  (boiled; 

8.  Fresh  liver  extract .  .    .    .    . 

9.  Fresh    mesenteric   lymph 

node  extract 

10.  Mesenteric  lymph  node  ex- 
tract after  extraction  in 
ice  chest  for  24  hours. .    . 


V.S. 


v.s. 

0 
0 

v.s. 

0 


v.s. 

0 


0 
0 

v.s. 


-1 " 


vs. 


0 

0 

T 
0 

0 
0 

0 

0 

0 

0 

0 
0 
0 

0 
0 
0 

v.s. 

0 

M. 

V  H, 

Salt 
solu- 
tion 
con- 
trol 


Di». 
tUled 
water 
con- 
trol 


0 


C. 

c. 
c. 
c. 

c. 
c. 
c. 

c. 
c. 


O-no    beemolysis;    T  -doubtful    hsemolysis;    V.S.  -very   slight    hemolysis;    M  -marked 
hamolysis;  C.  -complete  hKmolysis;  —  -no  test. 

From  these  obsenations  it  would  appear  that  fresh 
extracts  of  spleen  are  devoid  of  definite  ha-molytic  action. 
Occasional  irregular  results,  not  to  be  explained,  are  found, 
but  these  occur  likewise  in  the  control  extracts  of  liver 


REGULATORY  INFLUENCE  OF  THE  SPLEEN 


83 


I 


and  mesenteric  lymph-nodes.  Extracts  24  hours  old,  pre- 
pared at  low  temperatui'e,  show  little  or  no  increase  in 
hivniolytic  activity.  Boiled  splenic  tissue,  extracted  in 
the  cold  for  24  hours,  is  inert. 

From  these  results  we  are  forced  to  the  opinion  that 
our  present  methods  of  demonstrating  ha?niolysis  in  vitro 
are  not  adapted  to  proving  the  presence  of  a  ha?molysin 
in  fresh  extracts  of  the  normal  spleen,  and  we  are  inclined 
to  agree  with  those  who  believe  the  report  id  positive  results 
to  be  due  to  the  products  of  organ  autolysis  or  bacterial 
action.  Moreover,  we  believe  that  no  accuracy  can  be 
claimed  for  work  done  with  extracts  which  are  not  free  at 
tlie  outset  of  both  red  cells  and  ha?moglobin.  We  do  not, 
liowever,  deny  that  the  spleen  contains  a  hasmolytic  body. 
The  histological  evidence  of  the  presence  in  the  spleen  of 
cells  which  engulf  and  destroy  red  cells,  and  which  pre- 
sumably cause  this  destruction  through  a  ferment  action, 
forbids  such  an  opinion.  These  cells  may  contain  a  ha?mo- 
lysin  which  may  act,  as  Banti  suggests,  intracellularly, 
or,  when  they  are  destroyed,  extracellularly,  but  of  this  we 
have  as  yet  no  proof. 

(6)    Influence  of  Fatty  Acids  and  Lipoms  in 

HAEMOLYSIS 

Another  theory  of  Iwemolysis  is  that  which  involves 
the  action  of  fats  and  lipoids  and  with  which  are  associated 
the  names  of  Joannovics  and  Pick.^*'  This  is  based  on 
the  fact  that  larger  doses  of  toluylenediamine  are  necessary 
to  cause  icterus  in  splenectomized  dogs  than  is  the  case  in 
normal  animals  and  also  upon  the  fact  that  toluylenedia- 
mine is  not  ha?molytic  in  vitro.  It  is  evident  that  if  toluy- 
lenediamine is  hemolytic  in  vivo  and  not  in  vitro  some  factor 
other  than  the  drug  itself  is  concei  ned.    This  cannot  be  the 


«4 


THE  SPLEEN  AND  ANAEMIA 


spleen  alone,  for  in  splenectoniized  dogs  haemolysis  can  be 
produced,  if  large  enough  doses — two  to  three  times  the 
usual  amount — are  used.  Joannovics  and  Pick  found  that 
in  toluylenediamine  poisoning  they  could  obtain  from  the 
liver  a  hemolysin  soluble  in  ethyl  and  methyl  alcohol  and 
in  ether  and  acetone,  and  resistant  to  heat.  Between  acute 
and  chronic  poisoning  were  found  certain  differences.  In 
chronic  intoxication  the  ha?molysin  was  influenced  by  the 
absence  of  the  spleen,  that  is,  liver  extracts  from  splenecto- 
mized  animals  were  less  active.  In  acute  poisoning  the 
ha-molytic  power  of  the  liver  extract  was  not  influenced 
by  the  absence  of  the  spleen.  In  these  livers  were  found 
palmitic,  stearic,  and  oleic  acids.  Ha'molytic  bodies  simi- 
lar to  those  described  by  Joannovics  and  Pick  have  been 
found  in  human  livers  in  phosphorus  poisoning  and  acute 
j'ellow  atroph}--  (Jakoby).'"® 

Maidorn,^""  whose  experimentr.  are  in  general  confirma- 
tory of  the  observations  descril)ed,  finds  that  the  hasmo- 
lytic  substance  occurs  only  in  the  presence  of  fatty  de- 
generation. Eppinger*"*  and  King,^"  on  the  basis  of 
these  various  obsen-ations,  studied  the  fat  content  of  the 
blood  of  normal  and  splenectoniized  animals  and  of  a  num- 
ber of  indli^iduals  suff^ering  from  diseases  character'zed 
by  haemolysis,  in  order  to  determine  whether  any  of  these 
conditions  were  associated  with  an  increase  or  decrease  in 
the  blood,  of  unsaturated  fatty  acids.  According  to  their 
results,  the  blood  of  the  dog  after  splenectomy  shows  an 
increase  of  the  total  fats  and,  as  a  rule,  of  cholesterin, 
with  a  lowering  of  the  iodine  figure  representing  the  un- 
saturated fatty  acids ;  the  figures  for  the  cholesterin  esters 
were  variable.  Typical  experiments  from  King's  papers 
are  presented  in  Table  XXV  (a). 

These  figures  naturally  raise  the  question  of  the  pos- 


REGULATORY  INFLUENCE  OF  THE  SPLEEN    85 

sible  influence  of  cholesterin  and  the  unsaturated  fatty 
acids  in  changing  conditions  of  haemolysis  after  splenec- 
tomy.   The  change  in  fatty  acids  is  especially  important, 

TABLE  XXV  (a) 
I3LOOD  Fat  of  tle  Doq^  JEn.RE^  ^^d  After  SpLENtrroMY  (From  Kino"') 


Whole  blood 


\\  illi  spleen 

Withdiit  spleen,  14  days. .  . 
Withdiit  splet'ii,  2  months. 

Dog  9 

Sonmi — with  spleen 

Sruin— without  spleen, . .  . 
Corpusrlcs — with  spleen. . 
Corpuscles — without  spleen 


Total  fat* 


6.601 
9.085 
S.328 


4.449 

9.815 
3.883 
6.377 


Choleatcrin* 


CholeHferin 
eHlers* 


Iodine 
nurr  ber 


0.572 
0.617 
0,625 

0.120 
0.318 
0.393 
0.192 


0.306 
0.390 
0.309 


0.132 
0.348 
0.048 
0.262 


110.9 
12.3 
60.1 


101.2 
26.0 
53.8 
53.3 


•Figures  represent  grammes  per  1000  c.c   of  blood. 


TABLE  XXV  (6) 
liLooD  Fat  OP  THE  DoQ  Before  and  After  Splenectomy  (Dubin  and  Pearce") 


Kemarks 


JBIood  drawn  into  oxalate 
^Blood  drawn  into  o.xalate 

Blood  drawn  into  alcohol 
Blood  drawn  into  alcohol 
Blood  defibrinated 
Blood  deSbrinated 


" '^^^^''^^yi^"^^^^^'^!!:j^^Cb^^  --.  ''■ere  „,..  be 

as  Eppinger  found  that  in  a  variety  of  clinical  conditions 
ciiaractenzed  by  excessive  haemolysis  there  occurs  an  in- 
nease  of  urobilin  in  the  stools  which  goes  hand  in  hand  with 
an  increase  m  iodine  number  of  the  blood,  and  that  after 


86 


THE  SPLEEN  AND  ANEMIA 


splenectomy,  urobilin  sinks  to  normal  as  the  iodine  num- 
ber lessens.  Such  observations  have  obviously  a  definite 
relation  to  the  increased  resistance  of  the  red  cells  and  the 
decreased  tendency  to  jaundice  we  have  found  constantly  in 
the  dog  after  splenectomy.  As  a  preliminary,  therefore, 
to  experimentation  alon^  this  line,  we  repeated  the  studies 
of  Eppinjrer  and  Kin^  in  so  far  as  they  related  to  the  total 
fat  and  unsaturated  fatty  acids  of  the  blood  before  and 
after  splenectomy.*"*  Our  results  indicate  that  splenec- 
tomy has  no  influence  on  the  blood  fat  and  are  therefore 
not  in  accord  with  those  obtained  by  Eppinger  and  King 
(see  Table  XXV  [/;!). 

Just  how  the  spleen  might  influence  changes  in  the 
fat  and  lipoid  content  of  the  blood  it  is  difficult  to  see,  but, 
in  view  of  the  experiments  of  Anitschkow '  demonstrating 
the  deposition  of  anisotropic  fats  in  large  quantities  in 
the  spleen  of  the  rabbit  after  feeding  cholesterin  and  egg- 
yolk,  it  is  conceivable  that  the  spleen  stores  or  elaborates 
a  lipoid  concerned  directly  or  indirectly  in  ha?molysis,  and 
that  changes  in  this  function  may  be  a  factor  in  the  dimin- 
ished jaundice  caused,  after  splenectomy,  by  a  hemolytic 
agent.    This  hypothesis  is  sufficiently  attractive  to  justify, 
in  view  of  the  contradictions  between  our  work  and  that  of 
Eppinger  and  King,  a  delayed  opinion,  in  the  hope  that 
further  expcimentation  may  throw  more  light  on  this 
complex  problem.    In  this  connection  it  is  of  interest  that 
Kolmer  and  Pearce  "■*  have  shown  that  splenectomy  alone 
has  apparently  no  influence  upon  the  property  in  normal 
rabbit  and  dog  serum  of  fixing  or  absorbing  complement 
with  various  non-specific  lipoidal  antigens.     Such  effects 
as  were  observed  were  attributable  to  the  effect  of  the 
anesthetic  and  not  to  the  splenectomy. 


CHAPTER  IV 

CONCERNING  THE  SUPPOSED  REGULATORY  INFLUENCE 

OF  THE  SPLEEN  IN  BLOOD  DESTRUCTION 

AND  REGENERATION 

B.  IN  RELATION  TO  ANEMIA:  (1)  A  COMPARISON 
OF  THE  ARTERIAL  AND  VENOUS  BLOOD  OF 
THE  SPLEEN.  (2)  THE  INFLUENCE  OF  SPLENIC 
EXTRACT  UPON  BLOOD  FORMATION.  (3)  THE 
INFLUENCE  OF  FEEDING  SPLEEN  TO  SPLENEC- 
TOMIZED  ANIMALS.  (4)  THE  REPAIR  OF  AN 
ARTIFICIALLY  PRODUCED  AN.ffiMIA  IN  SPLE- 
NECTOMIZED  ANIMALS.  (5)  THE  INFLUENCE  OF 
THE  SPLEEN  ON  IRON  METABOLISM. 

Many  efforts  have  been  made  to  show  that  passage 
through  the  spleen  alters  the  red  cells  and  renders  them 
more  susceptible  to  haemolysis.  The  results  of  work  along 
these  lines  are  very  contradictory,  but,  as  our  problems 
demanded  a  first-hand  knowledge  of  the  subject,  we  have 
made  a  number  of  experiments  "**  in  this  field. 

(I)  A  Comparison  of  the  Arterial  and  Venous  Blood 

OF  THE  Spleen 

Much  of  the  early  work  on  this  subject  is  not  only 
contradictory,  but  was  done  before  the  development  of  the 
exact  methods  of  blood  examination  with  which  we  are 
now  familiar.  Thus  Virchow  "^  found  fewer  red  cells  in 
the  blood  of  the  splenic  vein  than  in  that  of  the  artery, 
Mhile  Malassez  and  Picard,^*^  and  Emilianow '"^  report 

87 


* 


I 


THE  SPLEEN  AND  AN.EMIA 


the  opposite.  On  the  t»ther  hand,  hiter  investigators,  Vul- 
pius **"  and  Paton,  (ruUand  and  Fowler,'^"  have  found  no 
constant  or  noteworthy  diff'erences. 

Considering  the  spleen  as  a  possihle  leucohlastic  organ, 
numerous  early  observers  found  relatively  more  leucocytes, 
especially  so-called  young  forms,  in  the  blood  emerging 
from  the  spleen  than  in  that  entering  it.  TarchanofF  and 
Swaen,''"'  as  also  Virchow,*^'  could  not  find  any  note- 
worthy difference,  whereas  Paton,  Gulland,  and  l^'owler  ^^" 
noted  a  constant  diminution  iw  the  number  of  leucocytes 
in  the  splenic  vein  as  compared  with  the  general  circulation. 
In  this  connection  Bulgak,"^  who  describes  an  increase  in 
leucoc\i:es  in  the  splenic  vein,  states  that  this  is  true  of  the 
venous  blood  of  all  parenchymatous  organs.  Freyer  '■'"' 
concludes,  from  his  comparative  counts,  that  the  spleen  has 
nothing  to  do  with  blood  formation. 

All  this  work,  of  course,  refers  to  mature  animals.  It 
is  generally  accepted  that  in  fetal  life  the  spleen  has  the 
power  of  extensive  blood  formation,  and  several  reports  are 
at  hand  to  show  that  in  the  adult  the  spleen  may  undergo, 
in  the  presence  of  injurj'^  to  the  bone-marrow,  a  myeloid 
metaplasia;""  that  is,  that  it  can  regain  its  fetal  function 
under  pathological  conditions.  Whether  or  not  the  spleen 
may  exert  this  power  of  blood  formation  in  the  adult  under 
normal  conditions  is  ver}"^  doubtful,  though  to  some  ob- 
servers it  is  still  an  open  question. 

On  the  other  hand,  although  the  spleen  certainly  de- 
stroys red  blood-cells  (as  is  evident  from  the  presence  in 
it  of  large  cells,  phagocytic  for  erji:hrocji:es,  which  are 
present  in  increased  numbers  under  certain  pathological 
circumstances) ,  there  is  still  some  doubt  as  to  whether  this 
destruction  by  phagocytosis  is  the  only  method  of  red-cell 


REGULATORY  INFLUENCE  OF  THE  SPLEEN    88 

(lisinteprration.  Many  investi^rators  claiiii  lliat  tlic  crythro- 
cytfs,  in  their  passage  throu/rh  the  spleen,  are  so  acted  upon 
hy  some  unknown  substance  as  to  become  more  susceptible 
to  lueniolysis. 

This  is  the  basis  of  Bottazzi's'^  hasmocatatonistic  theor>% 
which  has  recently  received  support  from  Banti  ="'  and  his 
colleague,  Fumo."^  In  the  course  of  an  investigation  of 
hii'inolytic  splenomegaly,  they  studied  normal  animals  and 
those  receiving  ha?niolytic  serum  and  came  to  the  con- 
clusion that  free  ha?moglol)in  can  l)e  demonstrated  in  the 
blood  of  the  splenic  vein  both  in  normal  animals  and  in 
those  receiving  hfemoiytic  serum.  Sometimes  they  found 
it  in  the  blood  of  other  vessels,  but  always  in  less  amounts 
than  in  the  splenic  vein.  These  findings  tiiey  consider 
«s  evidence  of  haemolysis  in  the  spleen.  Also  the  red 
blood-cells  of  the  splenic  vein  were  found  to  be  less  resistant 
to  hypotonic  salt  solution  than  were  those  of  the  general 
circulation.  On  the  other  hand,  investigations  by  Chalier 
and  Charlet"*  on  the  resistance  of  red  cells  in  the  splenic 
artery  and  vein  gave  very  different  results.  Although 
they  found  that  venous  blood  in  general  was  slightly  less 
resistant  than  arterial  blood,  in  the  splenic  system  this 
was  reversed,  so  that  the  blood  of  the  splenic  vein  was 
more  resistant  than  that  of  the  splenic  artery  and  much 
more  so  than  the  blood  of  other  veins.  Hammarsten  also, 
according  to  Gabbi/«»  found  that  the  splenic  vein  blood 
was  more  resistant  than  the  arterial. 

In  the  observations  of  Banti  and  Fumo,  the  reference 
is  to  free  htemoglobin  in  the  serum  and  not  to  the  increased 
haemoglobin  content  of  venous  or  splenic  blood  described 
by  several  investigators.  This  claim  is  most  surprising,  in 
tliat  they  state  that  the  dissociated  hemoglobin  of  the 


90 


THE  SPLEEN  AND  AN.EMIA 


serum  ("  emoglobin  (iist'iolta  dal  siero  ")  is  not  only  always 
present  in  the  splenic  vein  of  normal  animals,  but  some- 
times in  sufficient  quantities  to  be  measured  by  a  Sahli 
lutmoglobinometer.  It  is  to  these  observ-ations  that  we 
have  given  especial  attention  in  our  work. 

Methods. — From  dogs  under  ether  anjBsthesia  blood 
was  obtained  directly  as  it  flowed  from  the  splenic  artery 
and  the  splenic  vein.    Great  care  was  exercised  to  disturb 
the  vessels  and  the  organs  as  little  as  possible,  as  it  has 
been  shown  by  Grigorescu  ''^  and  Pribram  ■  '^  that  the  cell 
content  of  the  blood  may  be  greatly  increased  by  conges- 
tion of  the  spleen.     From  a  nick  in  the  wall  of  one  of  the 
branches  of  the  artery  or  vein  fresh  blood  was  drawn 
directly  into  Thoma  blood-counting  pipettes  -md  the  capil- 
lary tube  of  a  v.  Fleischl  hsmoglobinometer.    From  an- 
other branch  blood  was  withdrawn  by  a  s\Tinge  and  imme- 
diately distributed  to  tul>es  containing  different  strengths 
of  hypotonic  salt  solution  designed  to  test  the  resistance 
of  the  red  cells.    Some  of  the  blood  was  also  set  aside  for 
similar  tests  with  washed  cells.    For  the  determination  of 
the  presence  of  free  haemoglobin  in  the  serum  blood  was 
collected  in  three  ways:    (1)   in  a  paraffined  centrifuge 
tube,  (2)  in  a  tube  containing  potassium  oxalate,  and  (3) 
by  drawing  it  directly  into  tubes  through  capillary  points, 
which  were  then  sealed.    All  three  samples  were  centri- 
fuged  and  the  serum  examined  for  Iwuioglobin  by  visual 
inspection  and  the  spectroscope.    Smears  for  diff'erential 
counts  were  made  at  times  from  the  blood  flowing  directly 
^rom  the  vessel,  and  at  times  from  a  drop  from  the  syringe. 
Finally,  tests  for  reticulated  or  skeined  (young)  red  blood- 
cells  \v»re  made.    This  was  done  by  letting  a  few  drops  of 
blood  fall  into  a  solution  of  brilliant  cresyl  blue,  and,  after 


REGULATORY  UsFLLENCE  OF  THE  SPLEEN 


91 


standing  fifteen  or  twenty  minutes,  the  skeined  forms  in 
proportion  to  the  unskeined  or  mature  forms  were  counted 
in  fresh  smears.  For  the  purpose  of  controls,  blood  from 
the  femoral  vein  and  from  the  capillary  circulation  (by 
puncture  of  the  skin)  was  occasionally  collected. 

Results. — The  figures  -^*  for  the  red  and  white  cells, 
differential  counts,  and  total  hemoglobin  in  a  series  of 
five  dogs  show  that,  so  fai  as  these  estimations  are  con- 
cerned, the  blood  of  the  splenic  vein  does  not  differ  greatly 
from  that  of  the  artery.  The  variations  are  not  uniformly 
on  one  side,  and  are  all  within  the  limit  of  error  inherent 
in  the  methods  of  blood  examination.* 

It  is  of  interest  that  in  six  of  eight  animals  the  red  cells 
of  the  vein  showed  more  or  less  marked  anisocytosis  and 


*  Since  these  observations  were  made,  Morris '"'  has  published 
himilar  studies  on  the  cat.  He  comes  to  the  conclusion  that  Ihe  spV^u 
plays  a  definite  role  in  the  fomiation  of  the  red  blood-cells.  This 
conclusion  is  based  on  the  counting  of  the  red  cells  in  the  splenic 
artery  and  vein,  the  number  in  the  latter  being  one  to  four  million 
greater  than  in  the  artery;  in  one  animal,  for  example,  4,400,000  per 
c.nmi.  in  the  artery  as  against  9,120,000  in  the  vein.  Morris's  technic 
,'il)pt'ars  to  differ  from  ours  onlj'  in  that  he  collected  his  blood  from  the 
stagnant  stream  between  two  clamps,  while  we  took  the  free-flowing 
blood  as  it  passed  out  of  a  small  nick  in  the  vessel  wall.  Comparative 
tests  which  we  have  made,  since  his  publication,  of  stagnant  and  flow- 
ing splenic  vein  blood  show  that  sometimes  in  the  former  the  count 
may  be  one  to  three  million  higher  than  in  the  latter ;  in  other  instances, 
it  is  the  same.  We  are  therefore  inclined  to  think  that  Morris's  high 
counts  may  be  due  to  mechanical  causes,  especially  as  in  repetitions 
of  our  earlier  work,  three  dogs  being  used,  we  found  a  variation 
between  the  artery  and  vein  of  never  more  than  500,000  cells.  The 
liigher  count  occurred  twice  in  the  venous  blood  and  once  in  the  arterial 
Mood — variations  well  within  the  limit  of  error  of  blood-counting 
iiicthods. 


9t 


THE  SPLEEN  .VND  ANAEMIA 


inequality  of  staining,  which  were  not  seen  to  the  same 
degree  in  the  blood  of  the  artery.  Polychroniatophilia  was 
about  equal  in  blood  of  the  artery  and  the  vein.  In  two 
of  the  eight  experiments  a  few  normoblasts  were  found  in 
the  splenic  vein  blood  only.  Control  smears  from  the 
femoral  vein  of  four  dogs  showed  changes  in  the  red  cells 
about  equal  to  that  of  the  splenic  vein,  indicating  that  these 
changes  are  characteristic  of  venous  blood  in  general  rather 
than  any  specific  change  caused  by  passage  through  the 
spleen. 

In  regard  to  the  presence  of  free  hctmoglobin  in  the 
serum,  if  we  had  depended  on  one  tube  only  we  would 
have  occasionally  found  apparent  hitmoglobinicmia,  both 
in  the  general  circulation  and  in  the  splenic  vein;  but  as 
in  every  set  of  three  tul)es,  in  a  series  of  seven  dogs,  at 
least  one  was  free  of  htemoglobin,  we  cannot  support  the 
view  that  free  h.Tmoglobin  in  demonstrable  amomits  is 
present  normally  either  in  the  splenic  vein  or  the  general 
circulation  of  the  dog.  Our  experience  forces  us  to  the 
conclusion  that  the  findings  of  other  investigators  are  due 
to  hitmolysis  after  collection  or  are  dependent  upon  the 
method  of  separating  the  serum.* 

As  regards  the  resistance  of  the  red  cells  of  the  vein 

*  During  the  prist  few  years,  in  connection  with  investigations  on 
coagulation  of  blood.  Abdirlialden's  theory  of  protective  enzymes, 
Folin's  inicrochciniral  methods,  and  the  phenomena  of  ana))hylaxis. 
nuieh  time  and  attention  has  l>een  given  in  this  laboratory  to  the  collec- 
tion of  plar.ma  and  serum  from  the  dog  and  rabbit.  In  our  exi)erience 
careful  collection  always  yields  these  fluids  free  of  hemoglobin;  dis- 
colored sera  we  have  always  regarded  as  due  to  errors  in  the  method 
of  collection.  With  our  experience  in  mind,  we  cannot  support  the 
statements  of  Banti  and  I'urno  that  free  hn-moglobin,  in  amounts 
sufficient  to  be  recognized,  occurs  normally  in  the  serum. 


REGULATORY  INFLUENCE  OF  THE  SPLEEN         93 

as  compared  with  the  artery,  tests  were  made  on  eight 
dogs:  in  five  no  difference  was  found;  in  the  other  three 
the  venous  corpuscles  were  shghtly  less  resistant.  Two 
control  tests  with  cells  from  the  femoral  vtin  showed  these 
to  have  the  same  resistance  as  cells  of  the  splenic  vein  blood. 
The  question  arises,  therefore,  as  to  whether  the  differ- 
ences described  heretofore  are  not  those  of  arterial  and 
venous  blood  in  general. 

In  seven  comparative  tests  for  skeined  or  reticulated 
red  corpuscles  these  were  found  to  be  more  abundant  in 
five  in  the  splenic  vein  and  in  two  in  the  artery;  the  differ- 
ences were  never  very  striking.  Five  controls  from  the 
femoral  vein  corresponded  more  closely  to  the  splenic 
artery  counts  than  to  those  from  the  splenic  vein. 

As  a  result  of  these  various  observations  we  conclude 
that  the  slight  differences  tietween  the  arterial  and  venous 
blood  of  the  spleen  are  within  the  limits  of  error  inherent 
in  the  methods  of  blood  examination,  and  are  not  to  be 
explained  by  a  peculiar  action  of  the  spleen.  In  some 
instances  peculiaiities  shown  by  the  splenic  venous  blood 
are  common  to  the  venous  blood  of  the  general  circulation. 
Ranti  and  Furno's  observation  concerning  the  presence 
of  free  ha?moglobin  in  the  blood  of  the  splenic  vein  is 
not  confirmed. 


2.  Influence  of  Splenic  Extract  Upon  Blood 

Formation 
Xearly  all  investigators  grant  the  spleen  a  function  in 
the  destruction  of  red  cells;  and  some  ascribe  to  it  a  part 
in  red-cell  formation.  This  latter  view  is  based  largely 
on  the  fact  that  in  fetal  life  red  cells  are  formed  in  the 
spleen,  and  that  under  pathological  conditions  myeloid 


M  THE  SPLEEN  AND  ANEMIA 

metaplasia  may  occur.    We  have,  however,  no  satisfactory 
evidence  that  this  function  is  continued  under  normal  con- 
ditions beyond  a  short  period  after  birth.    Some  work  has 
been  done  with  splenic  extracts,  as  by  Danilewsky,'^  to 
show  that  the  spleen  contains  a  substance  which  stinmlates 
the  formation  of  red  cells  in  the  bone-marrow.     Danilewsky 
found  a  sin-prising  increase  in  ha-moglobin  and  red  blood- 
cells  after  a  single  subcutaneous  or  intraperitoneal  injection 
of  extracts  of  spleen.    This  increase  reached  its  height  in 
from  three  to  seven  days  and  continued  as  long  as  the  ex- 
periment lasted,  usually  eight  days.    In  dogs  with  a  dietary 
anaemia,*  splenic  extract  caused  an  even  greater  rise;  for 
example,  of  40  per  cent,  haemoglobin  and  almost  2,000,000 
red  cells.     This  influence  of  the  splenic  extract  was  not 
destroyed  by  heating.    Danilewsky  assumed  that  his  re- 
sults were  due  to  a  stimulation  of  the  bone-marrow.    As 
Danilewsky's  work  is  uncontrolled  by  injection  of  other 
organ  extracts,  we  have  repeated  his  experiments.   Silves- 
tri"*"®  records  a  single  observation  in  which  a  dog,  pre- 
sumably dying  from  ana?mia,  was  apparently  saved  by 
the  injection  of  splenic  extract.    In  this  connection  it  must 
also  be  noted  that  the  clinical  literature  of  this  subject  con- 
tains several  reports  of  the  use  of  extracts  of  spleen  and 
bone-nuirrow  with  good  results  in  the  treatment  of  anaemia. 

Method. — We  have  tested  the  effect  of  splenic  extract 
on  four  dogs,  using  as  controls  extracts  of  other  organs 
similarly  prepared  and  extracts  of  erythrocytes. 

The  usual  examinations  of  the  blood  were  made,  as 
were  also  determinations  of  the  resistance  of  the  erythro- 
cytes to  hypotonic  salt  solution  and  of  the  pei-centage  of 

iTAntemia  due  to  a  diet  of  rice  only;  red  cells  fell  to  3,980,000. 


REGUL:\.TORY  INFLUENCE  OF  THE  SPLEEN         95 


skeined  cells.  As  a  rule,  two  counts  were  made  before 
injection  and  daily  counts  after  the  injection  until  the 
blood  picture  had  returned  to  normal,  usually  a  period  of 
from  three  to  four  days.  Extracts  were  prepared  from 
organs  removed  aseptically  from  dogs  bled  to  death  under 
ether  ana?sthesia.  The  finely  chopped  organ  was  ground 
in  a  sterile  mortar  to  a  homogeneous  pulp  and  extracted 
with  double  the  volume  of  salt  solution  for  two  houx'S  in 
the  ice-chest.  Ten  cubic  centimetres  of  the  filtered  extract 
was  injected  intraperitoneally  into  dogs  of  about  the  same 
weight.  As  the  splenic  extract  contained  a  considerable 
amount  of  blood,  it  was  necessary  to  use  as  control  defib- 
rinated  blood  (10  c.c),  diluted  with  normal  salt  solution 
(T  to  20),  in  order  to  determine  the  possibility  of  the  rise 
in  red  cell  count  being  due  to  the  influence  of  some  con- 
stituent of  the  red  cells.  In  no  case  did  peritonitis  or  other 
infection  result  from  the  injection. 

The  result  ''^''  in  one  of  these  experiments  is  shown  in 
Table  XXVI. 

TABLE  XXVI 
Effect  on  the  Blood  Picture  of  Injections  of  Splenic  Extract 

Date 
(1914) 

Fel).    6 

Feb 


Feb. 


Feb. 
Fob. 

F'c!). 

Frb. 

Fol). 
Feb, 
Feb.  19 


7 

8 

9 
10 
U 

12 

13 
14 

ir< 

16 


HsBtnoglubin 

Red  blood  cells 

102 

5,250,000 

101 
(10  O.C.  splenic  extract  No.  16  injected) 

5,650,000 

110 

6,500,000 

(16  c.c.  of  same  extract  injected) 

110 

7,040,000 

105 

6,800,000 

96 

5,330,000 

95 

6,290,000 

(15  c.c.  splenic  extract  No.  88  injected) 

101 

6,700,000 

(10  c.c.  of  same  extract  injected) 

104 

6,880,000 

98 

6,8r<0,000 

% 

6,120,000 

106 

5,540,000 

96 


THE  SPLEEN  AND  ANiEMIA 


This  experiment  shows  that  intraperitoneal  injection 
of  splenic  extract  causes  a  sharp  rise  in  hsnioglohin  and 
red  cell  count,  lasting  only  one  or  two  days.  This  rise 
is  repeated  on  reinjection  of  either  the  same  or  another 
splenic  extract. 

In  each  of  three  other  experiments  with  splenic  extract 
an  increase  in  the  number  of  red  cells  was  obtained,  but 
this  increase  was  not  always  as  marked  as  in  the  experiment 
presented;  it  was  nevertheless  always  greater  than  that 
caused  by  the  use  of  control  extracts  of  liver,  kidneys,  or 

blood. 

The  study  of  the  resistance  of  the  red  cells  in  these 
experiments  may  be  dismissed  with  the  statement  that  no 
noteworthy  differences  were  found  after  injection  of  any 
extract.  The  skeined  cells  also  showed  no  constant  change. 
We  had  hoped  that,  as  the  latter  are  supposed  to  be  young 
forms  of  erythrocytes,  they  would  be  found  to  be  increased 
after  the  injection  of  splenic  extract  had  caused  a  rise  in 
the  red  cellcount.  Only  once,  however,  in  which  instance 
the  percentage  rose  from  0.5  to  2,  was  this  noticed.  On 
the  other  hand,  in  two  experiments  they  were  not  found  at 
all  in  the  blood  after  injection. 

Intraperitoneal  injection  of  splenic  extract  is  usually 
followed  by  an  increase  in  the  total  number  of  leucocytes, 
consisting  chiefly  of  the  polymorphonuclear  forms.  A 
similar  rise  occurred  in  one  of  three  experiments  with  liver 
and  kidney,  and  in  one  of  two  with  defibrinated  blood. 
Several  grades  of  "transitional  cells"  appeared  in  in- 
creased numbers.  Eosinophiles  were  present  in  increased 
numbers  in  two  of  the  four  dogs  receivir  g  splenic  extracts, 
liut  were  also  definitely  increased  in  two  of  the  five  con- 
trols receiving  other  organ  extracts. 


REG  lATORY  INFLUENCE  OF  THE  SPLEEN    97 

It  would  appear,  therefore,  that  the  intraperitoneal 
injection  of  saline  extracts  of  fresh  spleen  constantly  causes 
a  sharp  increase  in  red-cell  count  and  haemoglobin  content. 
The  rise  is  evanescent,  lasting  but  one  or  two  days,  and 
may  be  followed  by  an  equally  evanescent  drop  below 
noi-nial.  Similarly  prepared  extracts  from  other  organs 
fail  to  give  this  rise.  Xo  noteworthy  change  is  found  in 
the  resistance  of  the  red  blood-cells  to  hypotonic  salt  solu- 
tions or  in  the  number  of  skeined  or  reticulated  erythro- 
cytes after  the  injections  of  the  various  organ  extracts. 

A  temporary  increase  of  polymorphonuclear  and  tran- 
sitional leucocytes  usually  follows  the  use  of  spleen  ex- 
tract, but  may  occur  also,  but  less  frequently,  after  the 
injection  of  liver  and  kidney. 

The  constant  increase  of  red  cells  in  the  peripheral 
circulation  after  injection  of  spleen,  in  view  of  the  ten- 
dency to  anamia  following  splenectomy,  suggests  that  the 
spleen  normally  may  exert  a  stimulating  effect  upon  the 
formation  of  refl  cells  in  the  bone-marrow. 

3.   IXFLUENCF.  OF  FEEDING   SPLEEN  TO   SpleNECTOMIZED 

Dogs 
This  study  complements  that  just  described  in  that 
spleen  in  large  amounts  was  fed  to  splenectomized  ani- 
mals. The  object  was  to  determine  whether  through  the 
influence  of  some  necessary  substance  in  the  spleen  the 
ana>mia  following  splenectomy  might  be  prevented.  The 
procedure  is,  of  course,  analogous  to  thyn  Id  feeding  in 
insufficiency  of  the  thyroid  gland,  and  has  an  advantage 
over  the  injection  of  extracts  in  that  it  may  be  continued 
over  long  periods  of  time  without  the  possibility  of  the  com- 
plications occasionally  occurring  after  injection.     These 


98 


THE  SPLEEN  AND  ANAEMIA 


experiments,  it  was  hoped,  would  show  whether  or  not  the 
spleen  exerts  some  ett'ect  upon  the  hemopoietic  system 
through  peculiar  bodies  analogous,  perhaps,  to  those  of 
an  internal  secretion.  Thus  if  the  anremia  following  sple- 
nectomy depends  upon  the  absence  of  a  stinmlus,  fur- 
nished normally  by  the  spleen,  to  the  hfemopoietic  system 
in  general,  or  to  some  part  of  it,  as  the  bone-marrow,  the 
feeding  of  normal  fresh  spleen  unmodified  by  heat  or 
chemicals  might  supply  this  stimulus  and  there  would  then 
be  no  ana-mia  after  the  removal  of  the  spleen. 

Method. — Five  dogs  were  used.  Four  of  these  were 
given  a  diet  consisting  of  raw  hashed  beef  spleen,  lard, 
and  cracker-meal  in  amounts  estimated,  according  to  the 
weight  of  each  animal,  to  suit  its  caloric  needs.  Of  these, 
three  were  splenectomize<l  and  one  served  as  a  control.  As 
an  added  control,  a  splenectomized  dog  received  a  diet  in 
which  casein  was  substituted  for  beef  spleen.  The  red 
cells  and  the  hiemoglobin  were  estimated  several  times 
before  splenectomy  and  afterwards  counted  twice  a  week 
for  three  weeks  and  then  once  a  week  for  five  weeks.  No 
preliminary  counts  were  made  until  a  dog  bad  been  on 
the  special  diet  for  at  least  a  week,  and  splenectomy  was 
not  performed  until  two  weeks  later. 

Results. — Of  the  three  splenectomized  dogs  receiving 
spleen  ""*  in  the  diet,  one  showed  only  a  very  slight  de- 
crease in  red  cells  and  haemoglobin,  but  the  other  two  de- 
veloped the  usual  ansmia  of  splenectomy.  Thus  one  with 
an  initial  red-cell  count  of  6,200,000  showed  on  the  twelfth 
day  4,710,000  red  cells,  with  return  on  the  fifty-fourth 
day  to  6,040,000.  This  animal  received  daily  150  grammes 
of  beef  spleen.  The  other  dog  receiving  daily  275  grammes 
of  spleen  showed  a  change  in  red-cell  content  of  about  the 


REGULATORY  INFLUENCE  OF  THE  SPLEEN         99 

same  degree.  In  the  splenectomized  dog  not  fed  spleen  the 
leil  cells  fell  from  5,500,000  to  4,^10,000  on  the  19th  day, 
with  return  to  5,060,000  on  the  fifty-fourth  day.  In  this 
(log  the  haemoglobin  reached  its  lowest  level  (65  per  cent.) 
on  the  twelfth  day,  and  remained  at  about  that  point  until 
the  twenty-sixth  day.  In  none  of  the  other  splenectomized 
dogs  receiving  spleen  did  the  haemoglobin  fall  below  75 
per  cent.  The  normal  dog,  receiving  150  grammes  of 
spleen  daily,  showed  no  change  in  the  blood. 

It  is  evident  that  in  two  dogs,  despite  the  feeding  of 
spleen,  an  anfemia  was  produced  that  ran  a  course  very 
similar  to  that  which  we  have  previously  shown  to  be  the 
rule  in  splenectomized  dogs.  In  view  of  these  ver\'  definite 
results,  the  mildness  of  the  anemia  in  the  third  splenecto- 
mized dog  cannot  be  considered  as  a  sparing  influence  due 
to  the  feeding  of  spleen  tissue.* 


*  The  observation  has  recently  bet.  made  by  Lewis  and  Margot  '^" 
th.it  the  feeding  of  fresh  sheep  spleen  to  splenectomized  animals  gives 
rise  to  an  acute  intoxication  that  is  sometimes  fatal.  This  was  fre- 
oiitntly  observed  in  splenectomized  mice,  and  was  noted  in  one  of  two 
spleiuctoniized  dogs,  .vs  an  intoxication  such  as  Lewis  and  Margot 
desrribe  might  be  a  disturbing  factor  in  the  study  of  ana-mia,  we  have 
rtpiatcd  our  feeding  experiments  with  beef  spleen  and  have  watched 
witli  special  vigilance  for  the  appearance  of  symptoms  of  intoxication. 
One  dog  was  given  a  diet  of  raw  beef  spleen,  lard,  and  cracker-dust 
for  two  weeks  after  splenectomy,  and,  as  no  untoward  symptoms  had 
developed  in  that  time,  pure  beef  spleen  alone  was  given  daily  for  three 
days.  This  he  ate  with  relish,  devouring  over  1200  grammes  of  spleen 
during  these  three  days,  but  at  no  time  showed  any  signs  of  anorexia, 
mtisea,  vomiting,  chills,  or  in  fact  any  untoward  symptoms  whatsoever. 
Another  dog  was  fed  beef  spleen,  lard,  and  cracker-dust  for  ten  days 
befon  and  for  two  weeks  after  splenectcmy.  Neither  this  animal  nor 
tlic  nnrninl  control  on  the  same  diet  showed  a'  \  of  the  symptoms 
described  as  occurring  after  the  feeding  of  sheep's  spleen.     The  mod- 


H 


100 


THE  SPLEEN  AND  AN /EMU 


As,  therefore,  tlie  feeding'  of  fresh  raw  spleen  to  sple- 
nectoinized  dogs  has  no  clearly  deHned  influence  in  pre- 
venting the  anivniia  which  usually  occurs  after  splenec- 
tomy, a  regulatory  influence  of  the  spleen,  in  this  regard 
at  least,  cannot  be  assumed. 

4.  The  Repair  of  ax  Artificially  Produced  An.emia 
rx  Splexectomized  Animals 

In  the  hope  of  throwing  some  light  upon  the  problem 
of  the  regeneration  of  the  l)lood  in  the  absence  of  the  spleen 
we  have  allowed  animals  to  recover  from  the  aniemia  fol- 
lowing splenectomy  and  have  then  caused  ana-mia  in  vari- 
ous ways  and  followed  for  long  periods  of  time  the  changes 
in  the  blood  picture."'     These  studies  have  brought  out 
the  interesting  fact  that,  despite  the  increased  resistance 
of  the  red  cells  and  the  lessened  tendency  to  jaundice, 
the  anaemia  caused  in  splenectomir.ed  animals  by  hfemolytic 
agents  may  be  of  greater  severity,  as  shown  by  direct  blood 
examination,  and  always  nms  a  longer  course  and  has  a 
longer  period  of  repair  than  in  the  case  of  the  normal  dog. 
We  have,  therefore,  the  apparent  paradox  that  an  animal 
with  more  resistant  corpuscles  suffers  a  severer  and  more 
prolonged,  although  more  slowly  developing,  anaemia  than 
with  corpuscles  of  the  normal  resistance.     Before  further 
discussing  this  apparent  paradox,  our  methods  and  the 
results  of  detailed  experiments  may  be  presented. 

Methods.— Tl,^   animals   were   given   a   simple   but 

erate  ansmia  -which  dcvrloped  in  the  two  splenectomized  animals  fol- 
lowed the  course  usually  observed  in  splenectomized  dogs.  Considering, 
also,  the  three  dogs  previously  studied  by  us,  we  therefore  conclude 
that  the  phenomena  observed  by  Lewis  and  Margot  after  feeding 
sheep's  spleen  do  not  occur  in  splenectomized  dogs  fed  with  beef  spleen. 


■^i-r 


REGULATORY  INFLUENCE  OF  THE  SPLEEN       101 

abundant  diet,  practically  uniform  in  character  and  con- 
taining roughly  the  same  constant  amount  of  iron-yielding 
material.  The  iron  in  the  diet  was  not,  however,  in  this 
series  of  experiments,  estimated  quantitatively.  After 
preliminary  blood  examinations  had  been  made  the  spleen 
was  removed  aseptically,  by  a  practically  bloodless  opera- 
tion, under  ether  anJCstKesia.  The  blood  examinations 
were  then  continued,  at  first  at  short  intervals  and  later 
at  longer  intervals.  At  various  stages  of  the  prOv:ess  of 
l)l()od  regeneration  ha?molytic  immune  serum  or  sodium 
oleate  was  administered,  with,  at  the  same  time,  the  ad- 
ministration of  an  equivalent  amount  of  the  hemolytic 
agent  to  a  normal  animal  serving  as  control.  For  the 
j)urpose  of  further  control,  animals  were  rendered  aneemic 
by  bleeding,  in  order  that  the  regeneration  of  the  blood 
in  this  type  of  anaemia  might  be  contrasted  with  that  due 
to  hjemolytic  agents.  The  examination  of  the  blood  was 
continued  after  the  production  of  anaemia,  the  intervals 
between  examinations  being  gradually  lengthened,  and 
included  the  estimation  of  red  cells,  hjemoglobin  content, 
and  the  white  cells,  with  differential  counts  of  the  latter 
and  the  determination  of  the  resistance  of  the  red  cells  '  > 
various  percentages  of  hypotonic  salt  solution. 

The  two  experiments  given  in  detail  in  Tables  XXVII 
and  XXVIII  represent  the  longest  periods  that  animals 
have  been  obsen-ed  after  the  administration  of  haemolytic 
serum.  In  all  other  experiments  of  tliis  group,  although 
the  animals  were  carried  for  shorter  periods,  the  general 
course  of  the  ana?mia  was  the  same.  The  two  tables  are 
deemed  sufficient,  therefore,  to  illustrate  the  onset  and 
repair  in  this  type  of  ana?mia.  The  first  experiment 
(Table  XXVII)  is  of  interest  chiefly  in  connection  with 


"sl 


In 


lot 


THE  SPLEEN  AND  AN.EMIA 


the  question  of  the  len^h  of  time  necessary,  in  the  sple- 
nectoinized  as  coniparcd  with  the  norma',  dog,  for  a  com- 
plete regeneration  of  the  hlf)od  to  occur  after  the  destruc- 
tion caused  hv  hiemolvtic  serum.     It  will  he  seen  that  in 


tablp:  XXVII 

ErrecT  of  IIwEmolttic  Sebum  on  V  />od  Picture  or  Splbnectomized  Dou 

AND    Control  * 


Hsmolytic  Immune  Herum  61 


DoK  St.    Wriifht  s,li;()  gm    (2t) 

iaye  after  bdIp- 

Dog  53.     Weight  7,7S0  (tm    0  2.5  re.  h«pmolytic 

nectumyjO  I'i'.r 

hipniolylirseruiiiperkjlo  in  vein 

Berum  per  kilo,  injeeted 

lIipmoKluhin, 
per  cent 

Kc.J  bl.Kxi  cells 

liefore 

HsenioglohiD, 
per  cent. 

92 

Red  blood  cellj 

Before 

90 

5,230,000 

6,200,000 

23-2  hours 

72 

3,800,000 

3  hours 

78 

4,970,000 

1  day 

00 

3,5in,(XX) 

1  day 

38 

2,060,000 

3  days 

06 

3,920,000 

2  days 

30 

2,2,'iO,000 

6  days 

54 

2,730,(XX) 

4  days 

38 

3,100,000 

8  days 

38 

2,310,000 

6  days 

49 

3,420,000 

10  dava 

55 

3,100,000 

8  days 

42 

3,400,000 

14  davs 

48 

2,870,000 

10  days 

42 

3,110,000 

17  days 

53 

3,220,000 

12  days 

50 

3,980,000 

22  days 

51 

3,000,(X)0 

17  days 

64 

3,810,000 

28  days 

67 

3,510,0(K) 

24  days 

80 

4,230,000 

34  days 

M 

3,31H).(XX) 

31  days 

86 

4,, 530,000 

44  days 

76 

4,880,000 

66  days 

81 

5,120,000 

r)6  days 

85 

4,210,()(KJ 

86  days 

92 

5,380,000 

70  days 

63 

3,.')10,(KM) 

107  days 

105 

6,510,000 

79  days 

79 

4.120,(K)0 

100  davs 

86 

■1,01(),(KK) 

130  davs 

82 

4,J0(),(KK) 

200  days 

110 

6,200,000 

•  The  period  intcrvrninK  after  .«pleiiorromy  is  inclicatod  in  parenthewa  after  the  number 
of  the  uninial.  The  wDni  "■hcfnrf"  in  thi-  tiinL-  eolmnn  refers  to  Ihe  blood  count  niude  a  Mhort 
time  befon*  the  injection  of  the  hiPinolytir  a^enl  and  not  to  the  blood  count  before  Kplenrctomy. 
Likewise  hours  und  daya  in  the  ^a^ie  column  are  indicative  of  the  length  of  time  after  euch 
iajectioQ. 

the  normal  dog  the  lowest  figures  were  those  of  the  second 
day,  and  that  an  approach  to  normal  figures  was  evident 
after  two  months,  hut  that  the  latter  was  not  actually 
reached  in  the  case  of  ha'moglohin  until  the  third  month 
and  of  the  red  cells  until  107  days;  on  the  other  hand,  the 
splenectomized  animal  cxhihiting  a  more  gradual  fall  did 


REGULATORY  INFLUENCE  OF  TIIE  SPLEEN       lOS 

TABLE  XXVIII 

RECOVEBT    FbOM    iNiBCTION    OF    HEMOLYTIC    SeRUM    OP    SpLENE("rOMIZED    DoO 

A.ND  CONTBOL 


I 


Time 

July  24,  1912 
May  21, 1013 


l3t  injection 


24  lire,  later 


Ten  moDtba  ipleQectumy,  dug  59| 


Time 


CuDtrol.  dog  54 


2d  injection 
24  hre.  later 


2d  day. 


3d  day . 
4th  day. 


Splenectomy 
Weight  10,900  gm. 
Blood:  red  cells  5,200,000; 

ha-moglcjbin  86  [ler  cent. 
Fragility:  0.3+,  0.45- 
Urine:    no    bile-pigment; 

trace  of  alhuniiu;  no  casts 
0.2  c.c.  hemolytic  scrum    Istinjection 

{)cr  kilo.  : 


May  21,  1913  Weight  12,8a)  gm. 

j  Ulood:  red  cells  5,400,000 
ha'inoglohui  104i)er(ent. 
Fragility:  0.3 +  ,  0.5- 
I'rine:  not  obtained. 


Blood:  red  cells  4,820,000; 

hemoglobin  90  fwr  cent.; 

serum  free  of  hamoglobin 
Fragility:  0.35 +,  O.tj- 
Urine:   trace  of  albumin; 

trace  of  bile-pigment 


0.2  c.c.  per  kilo,  of  same 
i    scrum 

i  I'fine  shows  faint  trace  of 
;     bile  after  10  niin. 
24  hrs.  later  :  Blood:  red  cells  5,050,000; 
hamoglobin  94  [lercent. ; 
serum  f  reeof  hu'moglobin 
Fragility:  0.35 +  ,  0.6- 
L'rine;  trace  of  albumin; 
moderate  amount  of  bile- 
pigment  present 


Same  dose  of  same  serum    2d  injection 

rejieated 
Blood:  red  cells  5,620,000;    24  hrs.  later 

haemoglobin  95  fier  cent. 
Trine:     no     hamoglobm; 

faint  but  definite  trace  of 

bile-pigment;    trace    of 

albumin 
Blood:  red  cells  4,030,000;    2d  day. 

haemoglobin  75  per  cent. 
Urine:  bile-pigment  abun- 
dant   but   less   than    in  i 

dog  54 
Bl<K)d:  red  cells  3,950,000;    3d  day 

ha-mogl;bin  56  per  cent. 
I'rine:  gixid  bile  reaction, 

but   leas  than  in  dog  54 
Blood:  red  cells  3„580,000;    4th  day. 

haemoglobin  52  [icr  cent,  i 
Urine:  trace  of  bile 


5th  day [  Blood:  red  cells  3,550,000;    5th  day . 

[     haemoglobin  57  jier  cent. 
j  Urine:  bile  reaction  slight  ; 

7th  day Bhwvi:  rcl    nils  3,060,000;  ,  7th  day. 

ha-mogldl    i  52  per  cent,  j 
Urine:  no  aiiiumin  or  bile 


Same  dose  of  same  serum 

rejieated 
Blood:  rel  cells  4,880,000; 

haemoglobin  98  per  cent. 
Urine: slight  hamoglobin- 

uria;  large  amounts  of 

bite-pigment 

Blood :  red  cells  4,480,000; 
haemoglobin  97  jjer  cent. 
Urine;     no     ha-moglobin 

but    large    amount    of 

bile-pigment 
Blood :  red  cells  4,820,000; 

ha-moglobin  95  per  cent. 
Urine :  bile  very  al)undant 

Blood :  red  cells  4,460,000; 

hamoglobin  66  per  cent. 
Urine :     bile     decreasing, 

but  well  marked 
Blood :  red  cells  4,720,000; 

harnoglobin  74  {ler  cent. 
I'rine:  abundant  bile 
B.ood :  red  cells  S,,"- 00,000; 

ha'moplobin  S6  per  cent. 
Urine:  moderate  bile;  no 

albumin 


I 

3  4'' 


104 


THE  SrUEEN  AND  ANJEMLV 


TABLE  XXVllI— Continued 


Time 


Tua  moi  ih3  aphaeotomj  ,  dog  59 


Uth  day. . 

14th  day. . 
17th  day. . 

20th  day. . 

24th  day. . 

2;th  di'y 
3l8t  day. 

36th  day. . 

40th  day. . 
46th  day. , 


Weight:  10,040  gni. 
Blood:  red  cells  4,250,000; 

hamoglobm  54  per  cent. ; 

leucocytes  10,400 
Urine:  no  albumin  or  bile 
Blood:  red  cells  4,570,000; 

hajmoglobin  72  per  cent. ; 

leucocytes  14,200 
Urine:  faiat  truce  of  bile 
Blood:  red  cells  5,050,000; 

lia;moglobin  86  |)er  cent. ; 

leucocytes  16,000 
Urine:  no  albumin  or  bile 


Time 


nth  day.. 

14th  day . 
17th  day.. 

20th  day . 


Weight  10,415  gm. 
BlotKl:  red  cells  4,780,000; 

ha;mGglobin  7'J  per  cent. 

leucocytes  14,400 
Blix)d :  red  celi.i  5,440,000;    24th  day . 

ha;nioglobin  92  i)er  cent. 
Urine:  no  albumin  or  bile 
Blood:  red  cells  5,0m000; 

lia,'moglobiu  iK)  |)er  vi'Ut.  j 
Blood:  red  ceUs  3,480,0tH);  j  33d  day. 

hwnioglobin  70  jxjr  cent. 

leucocytes  13,400 
FragiUty:  0.275 +,  0.55- 
Blood:  red  cells  4,870, (JOO; 

liiemoglobin  98  [ler  cent. 
Urine:  no  albiunin  or  liile 
Blood:  red  cells  5,970,000; 

lut'moglobin  102  per  cent. 
Weight  10,820  gin.  46th  day. 

Blood:  red  cells  5,140,000; 

hajinogloliin  98  jier  cent. 
Fragihty:  0.35 +,  0.45- 


Control,  dog  54 


Weight  11,980  gm. 
Blood:  red  cells  5,800,000; 

haemoglobin  84  per  cent . ; 

leucocytes  17,000. 
Urine:  no  bile 
Blood:  red  cells  5,640,000; 

luemoglobin     102     per 

cent.;  leucocytes  18,200 
Urine:  faint  trace  of  bile 
Blood :  red  cells  6, 100,000; 

haemoglobin     106     per 

cent. 
Urine:  no  albumin;  very 

faint  trace  of  bile 
V\'eight  12,365  gm. 
Blood :  red  cells  6,080,000; 

hwrnoglobin      IW     per 

cent.;  leucocytes  20,700 
Blood :  red  cells  6, 120,000; 

ha'moglobin     110     per 

cent.;  leucocytes  13,200 


Blood :  red  cells  6,200,000; 
luemoglobiii  110  ;r 
cent.;  leucocvtcs  13,200 

Fragilit>  :  0.325 +,  0.55  - 


Weiglit  12,450  gm. 
Blood:  re<lcclls  |-.0t;(),000; 
hu'inoglobin  lot  (iJcr  cent. 
Fragility:  0..i5+,  0.55  — 


not  reach  its  lowe.st  figures  until  tlit  eighth  day,  and  still 
had  a  low  h;enioglo])in  content  and  red-cell  count  at  the 


endof  1*»'J 


On  acrount  of  the  long  intervals  elapsing 


in  each  case  before  the  final  count,  the  exact  dates  of 
return  to  normal  cannot  he  given,  but  it  is  clear  that  one 
month  after  the  control  animal  had  reachwl  its  normal  red- 
cell  count  the  blood  of  tlie  splenectomized  animal  was  far 
from  its  normal  state.    At  the  end  of  200  davs,  however, 


REGULATORY  INFLUENCE  OF  THE  SPLEEN        105 

the  blood  picture  of  this  animal  gave  liigher  figures  than 
before  injection. 

As  these  animals  were  of  practically  the  same  weight, 
and  as  the  splenectomized  dog  received  less  serum  than  the 
normal  dog,  it  is  impossible  to  escape  the  conclusion  that 
the  absence  of  the  spleen  is  an  important  factor  in  the 
chronicity  of  the  aiucmia  and  the  slow  repair. 

In  the  second  experiment  (Table  XXVIII)  the  same 
relative  difference  in  the  severity  of  the  ana?mia  and  th? 
rate  of  recover\'  is  seen,  but  in  neither  animal  was  the 
period  of  recovery  as  long  as  in  the  animals  of  the  first 
experiment. 

Some  objection  might  be  raised  against  the  results  in 
the  fir?t  experiment,  as  this  animal,  despite  the  high  initial 
count,  had  been  splenectomizetl  only  twenty-six  days,  and 
the  resulting  slow  repair  might  be  due  to  a  combination 
of  a  slow  an.-cmia  secondary  to  absence  of  the  spleen  and 
of  the  anfpmia  due  to  the  ha?molytic  serum.  This  possible 
objection  is  removed  by  the  results  in  the  second  experi- 
ment, in  which  the  blood  of  an  animal  splenectomized 
nearly  a  year  lx?fore  had  returned  to  normal  before  iniec- 
tion.  The  theory  that  the  absence  of  the  spleen  is  respon- 
sil)le  for  the  slow  blood  regeneration  is  thus  strengthened. 

Sodium  Oleate  Ancemia  in  the  Splenectomized  Animal 
On  account  of  the  advisability  of  determining  the  effect 
of  another  type  of  hemolytic  poison,  experiments  were 
made  with  sodiimi  oleate  (see  Table  XXIX).  This  sub- 
stance, unlike  haniiolytic  serum,  produces,  as  a  rule,  a  tran- 
sient an.Tmia.  quickly  repaired  in  the  normal  dog. 

Here.  also,  it  is  seen  that  the  anaemia  was  more  severe 
and  the  repair  slower  in  the  splenectomized  than  in  the 


106  THE  SPLEEN  ATsD  ANAEMIA 

normal  animal.  In  the  tirst  experiment  the  splenectomized 
dog's  haemoglobin  fell  eventually  on  the  thirtieth  day  to 
54  per  cent,  and  the  red  ce*  ,  to  3,700,000.  and  it  took 
forty-three  days  for  the  rttum  to  normal,  whereas  in  the 
control  receiving  an  equivalent  amount  of  oleate  the  hemo- 
globin fell  on  the  +hird  day  to  only  93  per  cent,  and  the 

TABLE  XXIX* 
RtPAiB  OF  Sodium  Oleate  Anemia  After  Splenectomy,  With  Contbol 


Dog  24.     Weight  n.fiM  pm.  (5  months  after               p^^  55     Weight  7,860  gm.     Normal 
splenectulny)  _____^ 


1m  c.e.  of  1  per  rent    sodium  oleate  in  vein     '     100  c  c.  of  1  per  cent.  »odium  oleate  in  vein 


Before 

Iday 

3  days 

7  days 

11  days 

16  d.iva 

19  days 

24  days 

30  days 

35  days 

39  days 

44  days 

51  days 

.57  (lavs 

73  (laVs 

200  days 


Hemo- 
globin 

R,-d  blood    Leueocytesl 
cells 

! 

per  cent. 

89 

5,650,0C()     10,(>00 

Before 

68 

3,770,(M)0     \:>XM 

3  davs  i 

70 

2,:j20.(XK)     10,400 

7day,s  ; 

74 

3.1{X).0<H)     10,S00 

16  diiys 

70 

4,20<).(MH)      ^,t)00 

24  days 

06 

:i,420,(«H)       9,MX) 

66 

:5,7t)0.(HX)     10,200 

63 

3,tK)0,0<H)     10,(KK) 

54 

liJOO.nn)      7,tf00 

63 

3,890,0(K)     1(),CKX) 

66 

4,1S0,0(«1       9,;«X) 

76 

4,220,0<K)     12,S(X) 

79 

4,400.000     i:i<)00 

86 

4,S20,(XX1      S,900 

90 

5,7S0,(KX)     12,r)00 

110 

6,04S,0(H) 

H,""""-       Red  blood 
globin  ^,ji|g 

per  <enl 


108 
93 
112 
116 
114 


Leucocytes 


6,460,000 
5,420,000 
1),120,0<X) 
7,240,000 
7,410,000 


8.600 
7,100 
6,400 
10,800 
8,200 


•The  data  in  this  table  are  arranged  in  the  same  munner  as  in  Table  XXMl. 

erythrocytes  to  only  .),420,000,  and  the  return  to  normal 
occurred  four  days  later.  In  a  second  experiment  the 
same  general  results  were  obtained,  but  in  less  striking 
form.  In  this  type  of  atiivniia  it  is  therefore  also  evident 
that  absence  of  the  spleen  delays  the  regeneration  of  the 
blood;  that  is,  interferes  presumably  with  the  normal  re- 
action of  the  bone-marrow. 


REGULATORY  INFLUENCE  OF  THE  SPLEEN       107 


Repair  of  Blood  in  the  S plenectomized  Dog  After 

Hemorrhage 

A  third  method  of  study  was  to  produce  ana3mia  by 

hemorrhage  and  to  observe  the  rapidity  of  repair  in  the 

splenectoniized  as  contrasted  with  the  nonnal  animal  (see 

Table  XXX). 

TABLE  XXX* 

Repair  After  H.BMORRnAoic  An.emia  in  a  Splenectomized  Animal,  with 

Control 


Dog  42.  Wd 

ght  8,020  gm 

.   (85  days  after  Bplenectomy) 

Dog  55.    Weight  7,860  gin 

Normal 

100  c.c.  of  blood  thken  from  a  vein 

IjU  c.c.  of  blood  taken  from  a  vein 

Haemo- 

glubin 

lied  blood  cella 

Leucocytes 

glubin 

Red  blood  cell! 

Leucocyiet 

per  cent. 

per  lent. 

Before 

92 

5,160,000 

22,400 

95 

5,200,000 

10,200 

1  day 

78 

4,570,000 

26,200 

78 

5,101,000 

8,300 

4  days 

68 

4,310,000 

24.100 

78 

4,900,000 

10,500 

8  days 

76 

3,820,000 

22,100 

105 

6,120,000 

10,400 

12  days 

85 

4,380,000 

16,800 



IS  days 

84 

4,210,000 

16,100 

26  da)-3 

70 

4,8,-)0,000 

17,400 

108 

6,460,000 

8,600 

84  (lays 

74 

4,100,000 

12,600 

40  days 

90 

4,480,000 

10,200 

46  days 

93 

4,390,000 

16,400 

54  dajs 

95 

4,700,000 

13,  UK) 

61  tlays 

90 

4,8")0,(KX) 

14,900 

67  days 

102 

5,100,0(X) 

19,200 

*  The  data  in  this  table  are  arranged  in  the  same  manner  as  in  Table  XXVII 

Here  it  is  seen  that  a  small  loss  of  blood  causes  a 
markedly  chronic  anaemia  in  the  splenectomized  dog,  and 
that  repair  is  greatly  delayed.  After  a  loss  of  100  c.c. 
of  blood  the  haemoglobin  of  the  splenectomized  dog  was 
lowered  on  the  fourth  day  to  08  per  cent,  and  the  erythro- 
cytes to  4,310,000,  with  a  return  to  normal  sixty-three 
days  later.  From  the  control  dog  of  slightly  less  weight, 
1.70  c.c.  of  blood  were  taken,  the  haemoglobin  dropping  to 
78  per  cent,  and  the  rc<l  cells  to  4,900,000  on  the  fourth 
day  and  promptly  returning  to  normal  by  the  eighth  day. 


108 


THE  SPLEEN  AND  AN^AUA 


Although  we  have  not  been  especially  interested  in  the 
changes  in  the  white  cells,  these  have  been  followed  in  some 
instances.  In  Table  XXXI,  which  follows,  the  leueocytic 
counts  of  the  animals  presented  in  Table  XXVII  are 
shown. 

TABLE  XXXI  * 
Leucocyte  and  Differential  Counts  After  H.emolttic  SERrM 


Dog  51 

(2G  daya  after  splenectomy) 

Dog  53. 

Normal 

Polv- 

Poly- 

mor- 

Small 

Eosin- 

mo  r- 

Small 

Eofiin- 

ophila, 

per 

phonu- 

lymph  ■ 

phonu- 

lyniph- 

Leucocytes 

clear 
cells. 

ocytes, 
per 

per 
cent. 

l.eucoeytes 

clciir 

ceils, 

orytea, 
per 

per 

cent. 

per 

cent. 

cent. 

cent. 

Before 

24,200 

86 

9 

3 

Before 

24,000 

71 

12 

6 

Idav 

1S,600 

Iday 

24,000 

92 

4 

1 

2  davs 

56,000 

4  days 

28,600 

3  davs 

28,400 

73 

8 

12 

8  days 

36,000 

6  days 

52,000 

10  diiys 

38,400 

81 

0 

8  days 

51,000 

So 

6 

5 

12  days 

31,200 

70 

2 

11  daya 

42,400 

73 

13 

s 

14  davs 

18,200 

68 

.-1 

2 

14  daya 

31,100 

63 

25 

5 

17  day.s 

17,800 

73 

24 

1 

17  daya 

17,200 

20  days 

13,200 

60 

32 

2 

28  days 

13,(X)0 

54 

20 

20 

24  davs 

14,1(X) 

66 

26 

5 

41  days 

US,()00 

60 

20 

Iti 

2S  davs 

19,100 

.51  days 

16,S00   !    5-1 

20 

17 

31  days 

11,900 

61 

28 

5 

62  davs 

l.S,(X)0 

65 

17 

14 

44  days 

16,100 

7'J  days 

17,200 

51 

24 

20 

59  davs 

11,200 

93  days 

1(1,400 

60  davs 

25,000 

78 

15 

5 

100  days 

12,2(K) 

72  days 

22,400 

136  days 

10,000 

50 

23 

24 

86  davs 

95  dai  s 

107  days 

19,100 
12,800 
10,200 

67 

OO 

2 

Normoblasts  aud  polychromatophiJia  Normoblasts  [)resent  after  injection  of 
constantly  present  after  injection  of  senim  for  17  days,  none  thereafter, 
senim  until  2Ntli  <lay.  One  normo-  I'olyrhromatopliilia  less  nuarked  than 
blast  seen  in  last  ooimt  i     in  dog  51 


•  The  ilat.i  in  this  tal)lc  are  arr.int:(il  in  the  smjie  manner  ni*  in  Tabic  XX\  II. 

It  is  evident  that  hemolytic  serum  causes  in  the  sple- 
nectomize<l  dog  a  leucocytosis  wliich  runs  higher  than 
that  in  the  normal  dog.  The  increase  in  cells  is  chiefly 
in  the  polynior])honuclear  leucocytes,  though  tliere  is  in 
both  normal  and  splenectoniized  animals  a  moderate  in- 


REGULATORY  LNFLUENCE  OF  THE  SPLEEN       109 

crease  in  the  lymphocytes  and  in  the  latter  a  persisting  in- 
crease in  the  eosinophiles. 

Another  interesting  point  concerns  the  change  in  re- 
sistance of  the  red  cells  after  administration  of  ha^molytic 
serum.  As  has  been  shown  in  an  earlier  chapter,  the  in- 
creased resistance  of  the  red  blood-cells  of  the  spleneeto- 
niized  animal  to  the  action  of  hypotonic  salt  solution  and 
to  hccmolytic  serum  is  "  not  due  to  an  increased  anti-ha?mo- 
lytic  power  of  the  animal's  serum  or  to  a  diminished  com- 
plementary value  of  the  serum,  but  is  a  property  of  the 
erythrocytes  themselves."  In  the  course  of  the  present 
investigation  it  v/as  noted  that  shortly  after  the  adminis- 
tration of  hfcmolytic  serum  the  cells  of  the  splenectomized 
animals,  instead  of  showing  a  greater  resistance  to  hypo- 
tonic solution,  became  less  resistant,  and  this  decreased 
resistance  persisted  in  the  splenectomized  animal  for  a 
longer  period  than  in  the  normal  animal.  This  is  shown 
in  the  following  abridged  table: 

T.\BLE  XXXII 

Resistance    of    Red    Blood-Corpuscles    After    Injection    of    H.<emolttic 

iSerl'm  * 


Dog  51.     (26  daj3  after  nplcnectoniy) 


Mefore  scrum  waa  administered 

3  hours  after  serum  was  adnih   stered 

0  (lays  after  scrum  was  admiui  icred 

S  to  ;J4  days  aft^r  senmi  was  a(iniinistore<l. . 
41  to  70  days  after  serum  was  administered 
100  davs  after  serum  waa  administered 


Dog  53,    Normal 


Before  serum  was  administered  

IS  hours  after  serum  wiis  administered 

>^  to  13  days  after  scrum  was  administered  . 
20  to  95  days  after  oc-rum  was  administered. 


Per  cent,  ult  Bolution 

.).2J 

0.3 

0.35 

0.4 

0.45 

0.5 

0.55 

+ 

+ 

P 

P 

o 

o 

0 

+ 

+ 

1' 

P 

p 

o 

() 

+ 

+ 

P 

P 

p 

p 

p 

+ 

-1- 

P 

P 

p 

p 

p 

+ 

+ 

P 

P 

p 

o 

() 

+ 

+ 

P 

P 

o 

o 

o 

+ 

+ 

P 

P 

0 



0 

0 

-1- 

+ 

P 

P 

p 

p 

p 

+ 

+ 

P 

P 

p 

p 

p 

+ 

+ 

P 

P 

p 

0 

0 

o 
o 
p 
p 
o 
o 


o 

() 
p 
o 


*  +  inilicstes  complete  bsmolysia:  I*,  partial  bcmolyaU,  and  O,  do  hamoljEis. 


i : 


U 


i,!  )| 


M 


110 


THE  SPLEEN  AND  AN.EMIA 


Here  it  is  seen  tluit  the  erythnxytes  of  the  splenec^to- 
niized  and  the  normal  dog  liad  tlie  same  resistance  to  salt 
solution  before  the  injection,  and  likewise  the  same  de- 
crease in  resistance  ei<^ht  days  after  the  injection  of  ha^mo- 
lytic  serum.  Tlie  cells  of  the  normal  animal,  however, 
returned  to  almost  the  ori<,''inal  :  esistance  after  iwenty 
days,  while  those  of  tlie  splcnectf)mized  animal  did  not 
return  to  the  same  de<j:ree  until  the  forty-first  day.  On 
the  other  hand,  it  will  he  seen  that  the  splenectomized  ani- 
mal returned  to  the  orig'inal  point  after  one  luuulred  days, 
while  the  normal  animal  failed  to  do  so  after  ninety-five 
days. 

In  the  ana-mia  j)roduced  by  sodium  oleate  the  de- 
creased resistance,  although  it  occurs,  is  not  so  striking 
in  either  the  normal  or  the  splenectomized  animal  as  it  is 
in  the  anamia  caused  by  hamolytic  serum;  the  s])lenecto- 
mized  animal,  however,  always  shows  a  greater  decrease 
in  resistance  than  does  the  normal. 

These  observations  may  be  summarized  as  follows: 

In  the  spleticctomized  dog  the  anamia  caused  by  hamo- 
lytic poisons  ( hamolytic  immune  serum  and  sodium  oleate) 
and  by  bleeding  usually  develops  more  gradually,  is  gen- 
erally of  a  severer  grade,  runs  a  longer  course,  and  is 
accompanied  by  a  less  rapid  regeneration  of  the  blood 
than  is  the  case  in  the  normal  dog.  Also,  in  the  splenecto- 
mized dog.  especially  after  the  use  of  hamolytic  serum, 
the  leucocytosis  is  greater  than  in  the  normal  animal. 

The  splenectomized  dog  almost  uniformly  exhibits  an 
increased  resistance  of  the  red  cells  to  hypotonic  salt  solu- 
tion, but  after  the  administration  of  hamolytic  poisons, 
and  especially  hcTniolytic  scnmi.  this  increased  resistance 
disappears  and  a  decreased  resistance  persists  for  varjnng 


REGULATORY  INFLUENCE  OF  THE  SPLEEN       111 

periods  of  time.  The  same  clian^e  occurs  in  the  normal 
do^,  but  in  the  latter  the  return  to  the  jjrevious  or  even 
increased  degree  of  resistance  is  more  rapid  than  in  the 
splenectomized  animal. 

These  results  show  that,  although  splenectomy  leads  to 
an  increased  resistance  of  the  red  blood-cells  and  to  their 
slower  destruction  on  the  administration  of  a  hfemolvtic 
agent — one  factor  in  the  lessened  tendency  to  jaundice 
and  to  hccmoglobinuria — yet  there  persists  that  same  ob- 
scure disturbance  which  induces  the  ana>mia  occurring  early 
after  splenectomy,  and  which  remains  present,  although 
latent  for  months,  rendering  any  new  ha>molytic  agent 
more  effective  and  delaying  the  recovery  from  the  anaemia 
which  it  causes. 

It  would  appear,  therefore,  that  of  the  phenomena  as- 
sociated with  the  absence  of  the  spleen,  two — the  increased 
resistance  of  the  red  cells  and  the  decreased  tendency  to 
jaundice  after  the  administration  of  hicmolytic  poisons — 
are  correlated,  but  that  the  aiicTmia  itself  is  dependent  upon 
some  factor,  as  yet  unknown,  which  operates  in  the  ab- 
sence of  the  spleen.  After  the  administration  of  a  ha'mo- 
lytic  agent  to  a  splenectomized  animal  this  unknown  factor 
dependent  on  the  absence  of  the  spleen  prolongs  the 
aiuenjia  and  retards  repair,  and  the  animal  does  not  recover 
as  quickly  as  does  the  normal  animal.  This,  at  the  present 
stage  of  our  knowledge,  is  the  only  explanation  of  the  more 
severe  and  more  prolonged  ana?mia  occurring  in  splenecto- 
mized animals  receiving  haemolytic  a^^-ents.  Nevertheless, 
the  increase  in  the  red  blood-cell  count  that  we  have  found 
to  follow  the  intraperitoneal  injection  of  splenic  extract 
suggests  that  the  normal  spleen  exerts  a  stimulating  effect 
on  the  bone-marrow,  which  naturally  is  lost  after  splenec- 


I 


If   ! 


112 


THE  SPLEEN  AND  ANAEMIA 


toniy.  It  is  probable  that  this  loss  may  at  least  contribute 
to  the  retardation  of  repair  in  splenectomized  animals,  but 
the  evidence  on  this  point  is  insufficient  to  allow  definite 
conclusions. 


5.   The  Txfluekce  of  the  Spleen  Upon  Iron 
Metabolis:m 

This  investifration  was  undertaken  to  determine 
whether  the  tendency  to  anemia  in  splenectomized  dogs 
and  the  delayed  regeneration  of  the  blood,  after  the  admin- 
istration of  hicmolytic  agents  to  such  dogs,  might  be  due 
in  part  to  some  influence  of  the  spleen  upon  the  iron  metab- 
olism, as  has  been  claimed  by  Asher  and  his  co-workers. 

Our  present  knowledge  concerning  iron  metabolism 
may  be  sunmiarize<l  as  follows:  Iron  is  absorbed  to  only 
a  very  limited  extent  from  the  gastro-intestinal  tract,  so 
that  when  al)undant  in  the  food  it  passes  from  the  intestine 
for  the  most  part  unchanged.  As  much  as  is  absorbed  is 
taken  up  chiefly  from  the  small  intestine  and  carried  by 
the  lymph,  to  be  deposited  in  the  liver  atid  to  a  lesser  extent 
in  the  spleen,  hone-marrow,  and  perhaps  elsewhere,  and 
this  occurs  whether  the  iron  l>e  in  intimate  organic  com- 
bination, the  so-called  food  iron,  incapable  of  giving  the 
characteristic  microchemical  reaction,  or  whether  it  be  in 
the  form  of  an  organic  or  inorganic  salt  of  iron.  Moreover, 
from  the  work  of  Hansermann  '''°  and  of  Abderhalden,^ 
it  appears  that,  though  iron  salts  are  absorbed,  the  body 
is  unable,  or  but  very  poorly  able,  to  utilize  them  for  the 
building  of  haemoglobin,  being  dependent  for  this  construc- 
tive work  upon  the  intimately  combined  food  iron.  On 
the  other  hand,  iron  salts  are  effective  stinmlants  to  the 


REGLXATORY  INFLUENCE  OF  THE  SPLEEN       118 

blood-fonning  organs  and  conspicuously  increase  the  utili- 
zation by  them  of  the  food  iron. 

The  elimination  of  iron  occurs  almost  wholly  through 
the  intestines,  especially  the  colon,  the  quantity  passing 
out  in  the  urine  constituting  less  than  one  per  cent,  of  the 
total  excretion  in  man  and  the  dog.     In  the  fasting  dog 
t!ie  output  found  by  Voit  ^''^  was  O.GO  mgm.  per  kilo,  of 
liddy  weight  per  day,  and  on  an  adequate  but  iron-poor 
diet  Gottlieb's  '''  dog  excreted  0.34  mgm.     For  man  the 
Hgurcs  are  lower.    Cetti  and  BreithauptJ"  while  fasting, 
eliminated  about  0.10  to  0.13  mg-  i.  per  kilo,  per  day, 
and  in  various  studies  on  man  0.10  to  0.25  mgm.  per  kilo. 
per  day  have  l^een  found  to  be  the  intake  required  to 
maintain  iron  equihbrium.     However,  there  is  ever\'  rea- 
son to  believe,  as  is  suggested  by  the  work  of  Schniidt,^*' 
who  fed  mice  for  months  on  a  diet  extremely  poor  in  iron, 
l)ut  obtained  no  fall  in  the  hemoglobin,  that  the  organism 
possesses  great  power  of  conserving  its  iron  and  of  reutil- 
izing  it  through  some  form  of  intermediary  metabolism. 
^Vhen,  however,  Schmidt  withdrew  iron  from  the  diet  for 
several   generations,    the  younger   generations   were   ex- 
tremely anemic,  and  this  anaem.ia  disappeared  upon  re- 
storing iron  to  the  diet.    As  the  iron-poor  diet  led  to  the 
disappearance  of  microchemically  demonstrable  iron  from 
the  liver,  but  affected  to  a  much  slighter  degree  that  of 
the  spleen,  Schmidt  concluded  that  the  liver  is  the  depot 
for  iron  from  the  food,  and  that  the  spleen,  on  the  other 
hand,  is  the  depot  for  iron  fron    tissue  and  erythrocyte 
catabolism,  and  thus  an  important  factor  in  the  interme- 
diary me'.abolism  of  iron. 

If  the  spleen  plays  this  part  in  iron  metabolism,  its 
absence  might  well  interfere  with  the  reutilization  of  iron 


j 


,4 


1 


114 


THE  SPLEEN  AND  ANAEMIA 


by  the  orguiiisin  and  lead  to  an  increased  iron  elimination, 
and  this  Asher'^  and  his  co-workers,  Grossenhacher '" 
a  1  Zinunerniann  ''  claim  to  have  demonstrated  in  dogs. 
X  ney  studied  the  iron  elimination  of  four  puppies  from  two 
litters;  one  from  each  litter  was  splenectomized  and  one 
from  each  kept  as  a  control.  The  iron  estimations  were 
made  at  intervals  of  a  few  weeks,  two  months,  and  ten 
months  after  splenectomy,  and  in  all  their  experiments  they 
found  an  output  nmch  higher,  often  double,  in  the  sple- 
nectomized animals  as  compared  with  the  controls. 

Methods. — In  our  earlier  experiments  we  studied  the 
iron  elimmation  during  four-day  periods,  but  found  that 
such  periods  led  to  irregular  results.  In  the  work  here 
reported,  therefore,  we  present  only  observations  based 
on  periods  of  longer  duration. 

The  animals  were  placed  in  metabolism  cages  with  glass 
floors,  and  afler  they  had  been  fed  for  several  days  on 
constant  weighed  amounts  of  the  diet  selected  the  rectum 
was  emptied  by  the  use  of  morpliine;  iron-free  charcoal 
was  added  to  the  next  feeding  and  the  collection  of  faeces 
begun  from  the  appearance  of  the  charcoal;  at  the  close 
of  the  period  the  rectum  was  again  emptied  with  morphine, 
carmine  added  to  the  next  feeding,  and  the  fa?ces  coUectetl 
until  carmine  appeared  in  them.  In  the  earlier  experi- 
ments the  urine  also  was  analyzed,  but  as  only  traces  of 
iron,  less  than  one  per  cent,  of  the  total  elimination,  were 
found  the  urine  was  omitted  in  our  later  analyses.  To 
avoid  the  introduction  of  extraneous  iron,  the  faeces  were 
collected  by  means  of  a  nickel  spatula  soon  l  '  n-  being 
j)asse<l. 

In  one  group  of  experiments  representing  the  earlier 
periods  after  operation  we  have  studied  the  output  of  iron 


REGUL.\TORY  INFLUENX'E  OF  THE  SPLEEN        115 

on  the  same  dogs,  hotli  l)ef'()re  and  after  splenectomy,  with- 
<tut  a  change  in  diet.  In  another  group,  representing  later 
periods,  we  have  compared  the  output  of  normal  control 
(logs  with  that  of  spleneetomized  dogs  of  approximately 
the  same  weight  on  corresponding  diets. 

The  analyses  were  made  by  the  meUuxl  of  Ripper  and 
Sehwarzer,  ^■•'  slightly  modified.  The  fjtces  cf)llected  for 
the  entire  period  are  placed  in  a  quartz  dish,  dried,  and 
ashed  dn,'.  The  ash  is  extracted  with  boiling  concentrated 
hydrochloric  acid  and  filtered,  and  the  residue  washed  with 
•JO  per  cent,  hydrochloric  acid.  The  residue  and  filter- 
paper  are  re-ashed  and  the  extraction  repeated.  This  ash- 
ing and  extraction  is  continued  until  the  extract  ceases 
to  give  a  positive  test  with  KCXS. 

The  total  filtrate  is  made  up  to  a  known  volume  and 
two  duplicate  portions,  containing  presumably  2  to  5  mgm. 
of  Fe  are  taken.  To  each  is  added  1  c.c.  of  Merck's  Blue 
label  IIiiO;;,  and  the  solution  evaporated  to  diyness  on  a 
water-bath.  The  residue  is  then  redissolve<]  in  1  c.c.  of 
■_*0  per  cent.  HCl  and  20  c.c.  of  boiling  water  used  in  four 
small  portions,  and  then  this  washing  with  acid  and  water 
is  repeated.  In  the  course  of  this  manipulation  the  entire 
solution  is  brought  into  a  200  c.c.  Erlcnmeyer  flask. 

All  the  specimens  to  be  analyzed  at  any  one  time  having 
lieen  brought  to  this  stage,  a  standard  is  prepared  Ijy  plac- 
ing in  each  of  two  200-c.c.  Erlcnmeyer  flasks  40  c.c.  of  a 
(juantitative  Fe-Cl,,  solution  containing  about  0.002  gm. 
Fe.  To  each  of  the  flasks,  those  containing  the  specimens 
and  the  two  containing  the  standard,  tiiere  are  added  in 
lapid  succession  4  gms.  of  KI,  the  flasks  immediately 
stoppered  and  placed  in  a  water-bath  at  60°  C.  for  ten 
minutes.    At  the  end  of  this  time  the  flasks  are  removed 


i ; 

fi 
It 


U 


116  THE  SPLEEN  AND  .VN^ML\ 

and  to  eacli  100  c-.c.  of  cold  water  are  iuuuediately  added 
and  the  Ihisks  rt-stoppered. 

To  eaeh  flask  in  turn  is  added  starch  solution  and  the 
contents  titrated  with  sodium  tbiosulphate  solution,  ap- 
proximately 1  "J .30  X,  until  disappearance  of  the  hlue 
color,  jr!id  then  immediately  titrated  with  weak  iodine  solu- 
tion hack  to  the  first  reappearance  of  the  hhie  color.  In 
taeh  analysis  the  thiosulphate  solution  is  freshly  prepared 
and  staiuiai-dized  against  the  two  flasks  of  known  FcjCki 
solution,  and  the  iodine  solution  also  is  freshly  prepared 
and  standardized  a^niinst  the  thiosulphate  solution.  The 
precision  of  the  titration  method  is  found  to  he  greatly 
enhanced  hy  the  titration  hack  with  iodine  to  first  reap- 
l)earance  of  the  hlue  color,  and  the  calculation  ai  dingly 
of  the  thiosulphate  end  point. 

In  control  experiments  performed  hy  adding  a  known 
amount  of  iron  to  one  of  identical  pairs  of  samples  of  ash 
of  tijeces  an  error  of  ahout  2  per  cent,  was  ohserved. 

The  food  used  in  these  ex])eriments  consisted  of  casein, 
cracker-meal,  lard,  and  fresh  heef  heart  in  proportions 
designed  to  give  the  desireu  an  ■  jnt  of  irun.  The  'ron 
content  of  the  food  was  determined  hy  analyzing  many 
large  portions  (each  50  gms.  to  400  gms.)  of  the  beef  heart, 
cracker,  and  casein  and  obtaining  average  figures  for  use 
in  calculating  the  iron  content  of  the  diets  employed. 

Rksults. — In  the  accompanying  tables  are  given  in 
detail  the  final  figures  obtained  in  our  studies."  The 
experiments  are  divided  into  two  groups:  First,  five  ani- 
mals on  a  constant  diet  were  studied  both  before  and  for 
two  weeks  after  splenectomy,  these  are  arranged  in  Table 
XXXIII  according  to  the  iron  content  of  the  diet.  Second, 
a  group  of  five  animals  (Table  XXXIV),  two  of  which 


REGULATORY  INFLUENCE  OF  THE  SPLEEN       117 

sened  as  normal  controls  and  three  for  purposes  of  study 
at  !(*ngcr  periods  after  si)lenectomy  than  are  represented 
hy  the  ^^roup  i;  •  Tah!e  XXXIII.  'Hie.se  five  do^s  were  of 
ahout  the  same  weight  and  were  on  diets  of  the  same  gen- 
eral character.  Iiut  varyin;^  in  the  content  of  iron. 

TAHLE  XXXIII 

EUMl.NATION    OF    Iro\    HeFORE    AND    AfTTR   Spl.ENEfTOMT 


"••^^"     '      ^^yS"        "%;X"'!      Intake. 

i 

l:utput' 

Time  «fter 
Bptfnectomy 

Before 
Bplcnet'torny 

0.67 
0.30 
0.87 
1.89 

1.88 

.\fter 
splenectomy 

88             7,000          10  davs    j       0.27 
30             5,340            9  davs           0.30 
35             7,720            9  (lavs    1       0.64 
44             9,000            9da"vs    i       1.57 
79              9,000       ,      9  (lavs            1.71 

0.70 
0.55 
0.81 
2.10 
2.21 

4-14  days 
1-10  davs 
1-10  days 
1-10  days 
C-lf)  days 

*  Figurea  rcprctieat  miUigrammes  of  iron  per  kilo,  per  day. 
TABLE  XXXIV 
Elimi.vation  of  Ino.v  in  \ok.mal  a.\d  Splenectomued  Dogs 

Xormal 


Control* 


Dog  No. 


Average  weight 


Duration  of     j 
peri(xl  I 


79  9,000  9  days 

44  9,(JO0       j        0  diivi 

79  ,         y,i>iO       I        9  days 


Intake  • 

1.00 
1.59 
1.71 


Output  * 


Time  after 
flplenectomy 


1.42 
1.89 
1.88 


Splenectomized 


83 

9 
51 


8,400 

8.800 
10,000 


10  days 
9  days 
9  davs 


1.42 
1.35 
1.32 


1.39 
1.56 
1.42 


27-37  dava 

9  months 

20  months 


*  Figuru'9  represent  milligrammes  of  iron  per  kilo,  per  day. 


Inspection  of  Tahle  XXXIII  shows  that  the  iron  out- 
puts of  Dogs  88  and  35  was  unchanged  hy  splenectomy,  hut 
tliat  Dogs  30,  44  and  79  showed  some  increase.  On  the 
other  hand,  in  Table  XXXIV  it  will  be  seen  that  all  three 
splenectomized  dogs  exhibited  an  output  of  iron  as  com- 


t  f 

•II 

! 


m 


118  THE  SPLEEN  .VXD  AN.EMIA 

pared  with  the  intake  elosely  comparable  with  that  of  the 
controls.     From  these  studies  it  would  appear,  therefore, 
that  during  the  tirst  two  weeks  after  splenectomy  some,  but 
not  all.  (logs  show  a  slight  increase  in  the  output  of  iron, 
but  that  at  one  month,  nine  months,  and  twenty  months 
after  splenectomy  we  lind  no  indication  of  such  increased 
iron  output.     The  occasional  evanescent  and  inconstant 
increase  in  elimination  of  iron  does  not  justify  the  conclu- 
sion that  the  spleen  exerts  an  important  intluenee  on  iron 
metabolism.  Our  results  are  obviously  different  f i-oni  those 
of  Asher  and  his  associates,  and  as  a  possible  explanation 
of  this  we  would  call  attention  to  the  extreme  shortness 
of  the  periods — one  to  three  days — employed  by  Asher 
and  Grossenbacher,  and  tc.  their  failure  to  mark  in  any 
way  the  stools.    In  the  studies  of  output  ten  months  after 
splenec-tomy,  as  given  by  Asher  and  Zimmermann,  the 
splenectomized  dog  in  most  of  the  experiments  was  much 
larger  than  the  control,  so  that  if  the  iron  output  of  their 
dogs  be  calculated  per  kilo,  of  body  weight  it  will  be  found 
that  the  output  of  the  splenectomized  animals  approaches 
ver\'  closely  that  of  the  normal  controls  and  is  in  some 
instances  identical.    It  seems  possible  that  in  these  studies 
ten  months  after  splenectomy  the  apparent  increase  in  iron 
output  of  the  splenectomize<l  animals  was  due  rather  to 
the  size  of  the  animals  than  to  the  s'denectomy.  and  it  is 
doubtful,  tlierefore.  whether  the  conclusions  of  Aslvr  and 
Zimmermann.  based  <m  these  experiments,  are  justified. 

It  is,  however,  difficult  to  explain  the  slight  increase 
in  the  elimination  of  iron  in  three  of  five  f)f  our  dogs  dm-ing 
a  period  of  two  weeks  following  splenectomy.  In  our  dis- 
cussion-^  of  this  first  study  of  iron  metabolism  we  stated 
that  possibly  the  occasional  increased  output  of  iron  might 


REGULATORY  INFLUENCE  OF  THE  SPLEEN       119 


liave  some  relation  to  the  aiutinia  which  occurs  in  the  early 
weeks  after  siilenectomy  and  which  varies  in  degree  in 
different  animals.  Later  investigations  offer  .some  sup- 
port to  this  hypothesis.  In  a  recent  study  '*'  in  which  four 
dogs  were  u.sed  in  an  investigation  of  nitrogen  metaholism 
hefore  and  after  splenectomy  the  elimination  of  iron  in  the 
fseces  was  determined.  The  methods  used  differed  from 
the  earlier  study  in  that  in  all  animals  the  iron  elimination 
was  determined  before  splenectomy  and  during  one  to  three 
periods  after  splenectomy,  and  also  in  that  Xeumanrj's 
method  ^"  of  determining  iron  was  used  instead  of  the 
Ripper-Schwarzer  method.  The  periods  of  study  varied 
from  five  to  eight  days  and  represented  intervals  of  three 
days  to  three  months  after  splenectomy.  As  the  dogs  were 
kept  in  all  periods  on  the  same  diet,  in  both  quantity  and 
(iuality,  the  iron  intake  was  not  determined.  The  results 
are  presented  in  Table  XXXV. 


i  i: 


I   I 

I, 

i; 


TABLE  XXXV  • 
Iron  Elimination  Before  and  After  Splenectomy 


Dog  No. 

Before  eplenectomy 

After  aplenectomy 

Period  I 

17.6 

10.5 

7.4 

10.9 

Period  II  t 
17.9 

10.4 

9.0 

10.8 

Period  III  t 

Period  IV  t 

48 
52 
56 
57 

Ifi.S 

9.8 

18.4 

9.9 

♦  Tho  fifcurea  in  this  table  represent  millifEramnien  of  iron  per  day  in  f»res. 
t  Thp  pi'rindfl  after  splenertomy  were  14  and  .=>.■)  dnys  for  dog  4H;  13,  41,  and  70  diivn  for 
dog  5J;  10  and  86  daya  fur  dog  5ft,  and  3  daya  for  dog  57. 

In  three  of  four  dogs  no  Important  change  in  the  elimin- 
ation of  iron  occurred  after  splenectomy.  In  the  fourth 
(Dog  56)  there  was  an  increase  of  1.0  mg.  per  day  during 
the  ptHod  (ten  days)  immediately  after  splenectomy, 
amounting  to  an  increase  of  21.6  per  cent,  over  the  fore- 


4 


:i  iS 


1^20 


THE  SPLEEN  AND  .VN^:M1A 


period.  In  the  final  period  three  months  after  splenectomy 
the  output  showed  an  increase  of  148  per  cent,  over  the 
fore-period  and  double  that  of  Period  II.  The  intake  of 
iron  was  not  determined,  hut,  since  the  food  i  take  was 
constant  throu^^iiout  all  the  periods,  we  liave  reason  to  be- 
lieve that  this  was  a  constant  factor.  Of  the  four  animals, 
two  showed  no  ana-mia  and  a  third  only  a  slight  reduction 
in  hivmo^lobin  and  red  cells.  The  fourth  do^  (No.  .56) 
showed  a  relatively  severe  ana-mia  (see  Table  I.I  1 1  in  sec- 
tion devoted  to  metabolism) .  As  this  last  dog-  was  the  only 
one  to  show  any  unusual  elimination  of  iron  after  splenec- 
tomy, the  question  naturally  arises:  Is  the  increased  elimi- 
nation of  iron  due  to  the  an.Tmia  or  to  the  absence  of  the 
spleen  f  We  incline  to  the  former  view  and  conclude  that 
the  spleen  exerts  no  constant  and  inijiortant  influence  upon 
iron  metabolism.* 


*  One  otluT  attempt  to  elucidate  tlie  iron  proMeiii  lias  been  the 
feeding  of  an  inorganic  salt  of  iron  before  and  after  spleneetoniy. 
Sucli  ex])eriinents  'n  the  normal  animal  are,  as  a  rule,  of  little  v  iliie, 
as  iron  so  ade  istered  is  not  absorbed  to  any  appreciable  extent,  but 
is  eliminated  .  most  eomi>leli  ly."''  It  seemed  worth  while,  however, 
to  see  if  any  change  in  absorption  occurred  in  the  absence  of  the  spleen. 
1  Avo  dogs  on  the  usual  eonstan!  diet  were,  therefore,  fed  daily  .">.")  mgm. 
of  iron  as  ferrous  sul|)h.ite  during  :i  ])eriod  of  one  week  before  and  ,i 
like  period  after  s])leii(  etomy.  In  e.ieh  inst.ince  the  second  l)eri()d  of 
analysis  began  four  days  .after  splcneitomy.  No  essential  or  constant 
difTerence  was  found  in  the  elimination  of  the  two  periods.  In  one 
animal,  of  ;"),'>  mgms.  of  iron  gi\en  daily,  .'iS  mgm.  were  eliminated 
daily  before  and  .'50..')  .after  splenectomy:  in  the  other  animal  the  figures 
wire  .'■)1.'2  before  and  .V,'..j  after  splenectomy:  essentially  negative 
results. 


l! 
!  !i 


CHAPTER  V 

CONTROL    EXPERIMENTS:     THE    DIVERSION    OF   THE 

SPLENIC  BLOOD  FROM  THE  LIVEB  WITHOUT 

REMOV.\L  OF  THE  SPLEEN 

(1)  BY  LIGATION  OF  THE  SPLENIC  VEIN,  (2)  BY 
TRANSPLANTATION  OF  THE  SPLENIC  VEIN  INTO 
THE  VENA  CAVA,  (3)  BY  ECK  FISTULA. 

IIiTHKUTo  in  all  our  discussions  of  the  phenomena 
f'ollowin^^  splenectomy— the  an;emia,  the  increased  resist- 
ance of  the  red  cells,  and  the  decreased  tendency  to  jaun- 
dice— we  have  assumed  that,  inasmuch  as  the  spleen  was 
ahsent,  the  changes  descrihed  are  prohahly  due  to  the 
loss  of  some  function  peculiar  to  that  organ". 

As  to  the  exact  nature  of  the  function  lost,  no  definite 
opinion  has  thus  far  been  given.  Three  possibilities,  how- 
ever, readily  suggest  themselves:  (1)  The  loss  of  some 
function  of  blood  destruction  or  regeneration  resident  in 
the  spleen  itself;  (2 )  the  loss  of  an  internal  secretion  acting 
on  the  distant  luemopoietic  tissues,  as  the  bone-marrow! 
and  (3)  the  obliteration  of  the  venous  drainage  of  the 
spleen,  which,  in  that  it  is  an  important  source  of  the  portal 
blood,  may  have  an  essential  relation  to  some  peculiar 
function  of  the  liver.  It  is  obvious  that  the  value  of  some 
of  these  hypotheses  might  be  tested  without  removal  of 
the  spleen  by  diverting  its  venous  outflow  from  the  liver. 
We  have  therefore  repeated  "'^  many  of  our  experiments, 
l)ut.  instead  of  removing  the  spleen,  the  splenic  vein  has 
either  been  ligated  or  transplanted  in  the  vena  cava,  or  an 
Kck  fistula  has  Ix^en  established.  So  far  as  we  know, 
exactly  similar  experiments  have  not  previously  been  at- 

121 


1! 


(  ; 
0 : 


>. 


Ui 


THE  SPLEEN  AND  AN.EMIA 

;l    1 
limber,  color,  and 


;i  hearing  on  the 


tempted,  though  two  ohservalions  1 
problem.     Xa^s;•ll•'•   found  that  t 
resistance  of  the  red  cells  remained  unchanged  after  simple 
Eck  fistula,  but,  as  he  gives  only  one  count  before  and 
one  after  the  operation,  his  observations  are  not  conclusive. 
The  other  report  wliich  concerns  us  is  Pribram's'"'  arti- 
ficial constriction  of  the  splenic  vein  with  resultant  passive 
congestion  of  the  spleen.     The  slight  anaemia  that  this 
caused  is  analogous  to  some  of  the  results  we  report  below. 
If  the  aiKcmia  following  splenectomy  is  caused  by  the 
removal  with  the  spleen  of  some  necessary  factor  in  blood 
formation  or  of  a  hormone  essential  to  the  hannopoietic 
tissues,  this  factor  should  not  operate  in  the  vein  trans- 
plantation and  'Ick  fistula  experiments  unless  it  is  also 
essential  that  such  a  substance  have  direct  approach  to 
the  liver  for  its  proper  functioning  or  activation.     If,  on 
the  other  hand,  the  aiuemia  is  largely  due  to  the  inter- 
ference with  the  supply  of  sjilenic  blood  to  the  liver,  it 
should  occur  in  all  the  animals.     These  problems  and  also 
that  concerning  the  influence  of  the  experimental  pro- 
cedure on  increased  resistance  of  the  red  cells  will  be  con- 
sidered  first,  and  then   j>roblems  such  as  the  decreased 
tendency  to  jaundice  and  the  prolonged  repair  of  ana[?mia 
in  the  splcnectomized  animal  when  hiPinolytic  agents  are 
given. 

Methods.— Tn  the  ligation  experiments  it  was  found 
necessary,  on  account  of  the  immerous  branches  and  the 
anastomoses  of  t^e  splenic  vein  with  veins  from  the 
stomach,  to  tic  all  branches  of  the  splenic  vein  shortly  after 
they  left  the  spleen.  In  the  earlier  operations  one  of  the 
subdivisions  of  the  artery  was  also  ligated.  to  lessen  the 
supposed  danger  of  rupture.     This,  later,  was  abandoned 


CONTROL  EXPERIMENTS  123 

vhen  it  was  found  to  be  uiuieccssarv  as  well  as  undesirable 
on  account  of  infarct  production.  Post-mortem  examina- 
tion of  animals  subjected  to  this  operation  showed  in  each 
case  that  all  brandies  had  been  tied,  that  the  vessel  beyond 
the  li^ration  was  much  diminished  in  size  or  completely 
obliterated,  and  that  there  was  usually  little  attempt  at 
compensatory  development  of  new  veins  from  the  adherent 
omentum.  When  such  new-formed  veins  were  present  it 
was  found  that  seldom  did  they  empty  into  the  portal  system 
and  therefore,  as  a  rule,  did  not  complicate  the  experiment. 

Yjck  fistula  was  performed  in  the  usual  manner,  the 
proximal  end  of  the  portal  vein  being  tied  off  above  its 
new  anastomosis  with  the  vena  cava  just  before  its  entrance 
into  the  liver.  Transplantation  of  the  splenic  ve-'n  into  the 
inferior  vena  cava  ])resented  considerable  difficulty  on 
account  of  the  smallness  of  the  vein  and  the  necessity  of 
stretching  it  a  little  to  make  it  reach  the  vena  cava.  In  only 
one  experiment,  however,  was  it  found  that  the  trans- 
j)lanted  vein  had  been  occluded  by  thrombus.  The  success 
of  the  operation  was  always  determined  by  examination 
of  the  vessels  at  autopsy,  and  in  some  instances  injection 
specimens  were  prepared  and  dissected  to  make  doubly 
sure  that  no  new  anastomoses  had  formed. 

The  particular  phenomena  studied  were  (1)  the  quanti- 
tative changes  in  counts  of  the  red  blood-cells,  leucocvtes, 
and  haemoglobin;  (2)  the  resistance  of  the  red  cells  to 
hypotonic  salt  solution;  (3)  the  general  condition  of  the 
animals  as  indicated  by  their  weight  and  condition  of  the 
urine,  and  (4)  the  gross  and  microscopical  appearance  of 
the  organs  at  autopsy. 

The  dogs  were  kept  on  the  usual  mixed  diet  of  "  table 
scraps,"  which  has  been  shown  to  maintain  properly  normal 


ill 


124  THE  SPLEEN  AND  ANEMIA 

dogs  as  well  as  those  convalescing  from  operations  other 
than  splenectomy  without  the  development  of  ana'mia."' 
Our  studies  have  been  made  on  twelve  dogs,  grouped 
as  follows:  Ligation  of  splenic  vein,  4;  transplantation 
of  splenic  vein,  2;  Eck  Hstula.  'J:  and  as  controls:  Sple- 
nectomy, 8;  transplantation  of  thr  inferior  mesenteric 
vein,  1.'  In  the  case  of  the  last  dog  it  was  intended  to 
transplant  the  splenic  vein,  and  it  was  not  until  autopsy 
that  we  found  that  the  inferior  mesenteric  vein  had  been 
used  by  mistake. 

Changes  in  the  Spleen 
In  those  dogs  in  which  all  branches  of  the  splenic  vein 
had  been  ligated,  and  in  \\hich  adetjuate  new  venous  chan- 
nels had  failed  to  develop,  the  spleen  showed  considerable 
change.  Before  the  operation  was  completed  the  spleen 
had  increased  to  almost  double  its  size  and  taken  on  a  dark- 
purple  color,  li'  the  animal  was  allowed  to  survive  two 
or  more  months  the  spleen,  at  a  itopsy.  was  found  to  be 
considerably  smaller  and  much  firmer  than  normal.  The 
capsule  was  slightly  thickened  and  jjuckered,  and  the 
organ  had  a  pale-bluish  coloi".  On  section  the  tissue  cut 
with  increased  resistance.  A  few  small  shrunken  infarcts 
were  occasionally  foun<l.  The  cut  surface  was  less  bloody 
than  usual  and  showed  an  increase  of  fibrous  tissue,  with 
indistinct  Malpighian  corpuscles.  Histologically,  the  tis- 
sue appeared  to  be  condensed,  with  collapse  of  "che  sinuses, 
rather  than  to  exhibit  true  fibrous  hyperplasia.  Some 
ha-mosiderin  pigment  was  found,  the  INfalpignian  cor- 
puscles were  small,  and  here  and  there  were  small  areas 
of  hyaline  degeneration  which  did  not  respond  to  TiUgol's 
test.     Thromboses  w^re  not  found  except  in  connection 


CONTROL  EXPERIMENTS 


125 


with  old  post-operative  infarcts.  In  the  earher  experiments 
in  wliieh  a  branch  of  the  arterj'  was  also  ligated  a  bulging 
hcniorrliagic  infarct  appeared  in  the  corresponding  area 
of  the  spleen.  The  neighboring  lymph-nodes  and  the 
liver  were  apparently  unchanged.  Speculation  as  to  the 
adjustment  of  the  splenic  circulation  in  the^e  cases  must 
remain  unsatisfiefl.  The  most  prol>al)le  evph,,uation  seems 
to  be  that  the  elastic  spleen  is  able  not  only  to  accommo- 
date the  increasing  pressure  without  rupture,  but.  with 
the  aid  of  the  minute  capillaries  in  the  adherent  omentum, 
to  maintain  sufficient  degree  of  nutrition  to  prevent  Jiecro- 
sis.  We  have  seen,  however,  that  the  exchange  is  not 
sufficient  to  prevent  atrophy. 

At  the  time  of  the  operation  for  Eck  fistula  and  the 
splenic  vein-vena  cava  anastomosis  there  is  necessarily  a 
temporary  (X'clusion  of  the  large  veins.  The  spleen  and 
intestines  I>ecome  verv'  dark  and  turgid,  hut  when  the 
clamps  are  removed  these  organs  return  quickly  to  normal 
color.  In  animals  so  treated  no  changes  are  found  at 
autopsy  except  adhesions  and  perisplenitis. 

Changes  in  tiie  Blood 

All  example  of  the  changes  in  the  blood  which  occur 
after  ligation  of  the  splenic  vein  is  given  in  Table XXXVI. 

It  may  be  seen  that  *'  is  animal  developed  a  moderate 
degree  of  anaemia  lasting  several  weeks  and  similar  to,  but 
less  severe  than,  that  following  splenectomy.  The  ana?mia 
is  accompanied  by  a  temporarv'  slight  increase  in  resistance 
of  the  red  cells  to  hypotonic  salt  solution.  As  in  splenec- 
tomy, there  is  an  immediate  leucocytosis,  due  to  polymor- 
phonuclear and  transitional  fonns,  but  prolonged  by  a 
more  persistent  IjTnphocji^osis  and  eosinophilia. 


f : 


126 


THE  SPLEEN  AND  ANEMIA 


A  very  slight  drop  in  weight  oceurs  after  operation, 
hut  later  there  is  a  distinct  increase  above  the  original 
weight.  It  has  been  shown  elsewhere,-'^'  by  the  study  of 
control  operations  such  as  nephrect(jniy,  that  the  esults 
here  descril)ed  are  not  merely  post-operative.  Other  dogs 
with  ligated  veins  gave  similar  results,  as,  for  example, 

TABI^  XXX\"I 
Blood  Changes  Followino  LauATio.v  of  Splenic  Veins 


a 

!  . 

HiDmolysia  •    \     ^ 

0 

i 

..;. 

'Z 

Ued  UooA 

1     ^S 

p*  « 

g 

« 

JS 

Dog  47 

0 

cells  per 

1     "  s 

•-  fc- 

*'  a 

•C 

1 

cmm. 

=  £ 

»1 

1 

^ 

5 

Begins 

Com- 
plete 

2» 

e  a 

o  a 

"5  ^ 
Eo 

u  S 

o 

■J 

S 

1^ 

CL, 

CO 

"^ 

i* 

per 
crnt. 

kxlc. 

Before 

102 

6,275,000 

0.475 

0.35 

9,S0o!  7,200 

700 

1,800 

100 

6.0 

1  (lay  after 

ys 

6,110,000 

19,00015,200 

950 

2,850 

0 

5.7 

4  (lays  after 

92 

5,;}5(),(KK)  0.475 

0.275 

16,500 

5.6 

1  week  after 

IK) 

5,520,OO(J  0.425 

0.275  il6,S00  13,600 

1,3(X) 

1,600 

300 

5.4 

2  weeks  after 

72 

4,9(K),0(M1  0.425 

0.3 

18,80015,400 

1,<.KK)   1..500;    0 

3  weeks  after 

70 

4,tK10,(«X)  0.45 

0.3 

21,(XX)  16,800 

3,100  i    300i300 

4  weeks  after 

78 

5,000,(KX) 

18,600 

6.4 

.5  weeks  after 

74 

4,;5SO,(KM)' 

15,000 

7  weeks  after 

SO 

5,aio,ooo 

0.475 

0.275 

12,80010,000 

1,700  i,ioo;  0 

7.3 

10  weeks  after 

82 

5,0.')0,00() 

0.45 

0.3      112,400 

12  weeks  after 

95 

5,S30,00(» 

0.475 

0.325  14,800  9,500 

3,400 

1,500  400 

7.5 

1,'5  weeks  after 

92 

l),4 10,000  0.475 

0.35     14,<KX>  9,200 

3,600 

1,200' 900 

14  weeks  after 

95 

1  6,150,0001 

15,60012,200 

2,500 

1    ' 

600 

100 

7.4 

*  The  figures  in  those  coldmns  refer  to  the  strongest  perrentflceg  of  salt  solution  in  which 
hnmoly^ia  was  drat  nuticcj  ami  in  which  complete  hieniulyais  lirat  occurred. 

Dog  .51  with  a  nuixiiniim  drop  of  14  per  cent,  of  hitmoglo- 
bin  and  1,200,000  red  cells,  and  Dog  74  with  a  hivmoglobin 
loss  of  24  per  cent,  and  in  red  blood-cells  of  1,800,000. 

The  effect  of  diverting  the  splenic  venous  blood  from 
the  liver  by  transplanting  the  splenic  vein  into  the  vena 
cava  is  shown  in  Table  XXXVII. 

Many  of  the  same  changes  as  after  ligation  are  found 


CONTROL  EXPERIMENTS 


lil 


liere.  In  another  dog  (No.  71)  siniiJarly  treated  the  in- 
creased resistance  was  much  more  marked;  before  opera- 
tion, hsemolysis  began  at  0.50  and  was  complete  at  0.35; 
soon  after  operation  it  began  at  0.425  and  was  complete 
at  0.25.  Anaemia  was  also  present,  as  shorni  bj-  a  drop  of 
20  per  cent,  in  ha-moglobin  and  of  1,800,000  red  blood- 
cells.    A  third  animal  (10)  lost  35  per  cent,  hemoglobin 

TABLE  XXXVII 


Blood  Changes  Following 

Anastomosis 

OF  THE  Splenic  Vein  ^ 

'iTH 

THE 

Vena  Cava 

a 

Hamolyais  • 

• 

0 

a 

'S 

s 

jg 

Dog  4 

^ 

Red  blood 

l-e 

t£ 

B 

12 

c  r 

s 

cmm. 

Begiua 

Com- 
plete 

e  a 

o  a 

1    a- 

■e 
o 

1 

•*' 

— 

0. 

a          tJ 

K 

^ 

per 

cent. 

1 

kilot. 

Before 

97 

6,960,000 

0.45 

0.35 

16,100 

8,400 

4,70011,600 

1,400 

9.4 

1  day  after 

104 

7,(M0,000 

0.425 

0.3 

34,000 

29,600 

3,100 

1,3001    0 

1  week  after 

75 

5,.5.50,000 

0.45 

0.3 

19,300 

12,400 

3,700 

1,900 

1,30Q 

9.7 

2  week;  after 

68 

5,020,000 

0.475 

0.275 

16,900 

11,800 

2,7-^) 

2,200 

20f| 

9.4 

3  weeks  after 

70 

4,530,000 

96 

4  weeks  after 

SO 

4,510,000 

0.475 

0.3 

14,700 

9,600 

2,800 

1,500, 

son 

10.4 

5  weeks  after 

74 

5,440,000 

0.475 

0.325 

14,000 

9,800 

2,800 

420| 

1,08(1 

10.5 

6  weeks  after 

78 

5,630,000 

0.45 

0.3 

11,200 

6.300 

4,000 

560' 

36(1 

<  weeks  after 

82 

5,770,000 

0.45 

0.325  1 

11,100 

7,400 

2,900 

200 

60(1 

12.9 

8  weeks  after 

S5 

6,060,000 

0.45 

0.325 

'.»  weeks  after 

96 

6,500,000 

1 

1 

13.2 

*  The  fiKurcs  in  these  coliimna  refer  to  the  utrongent  porrentages  of  anlt  solution  in  which 

ha^mulysis  w:«  tJral  noticed  uuil  in  which  complete  haimolyais  firat  orcurnd. 

and  o>  a-  2,000,000  erythrocytes,  and  a  fourth,  22  per  cent, 
hemoglobin  and  over  1,000,000  en'throcytes. 

The  changes  in  an  Eck  fistula  experiment  are  seen  in 
Table  XXXVIII. 

In  another  Eck  fistula  dog  (Xo.  68)  the  increased  re- 
sistance of  the  red  cells  was  more  marked  (before  opera- 
tion, haemolysis  began  at  0.45  and  was  complete  at  0.3; 
soon  after  operation  it  began  at  0.425  and  was  complete 


S'"--! 
ii:)i 


I        44, 


128 


THE  SPLEEN  AND  .\A^MIA 


at  0.225),  and  the  ani.iial  lost  33  per  cent,  hajmoglobin 
and  2,000,000  red  hlootl-cells  in  four  weeks'  time  after 
operation.  In  a  third  (Xo.  5)  with  an  even  greater  drop, 
the  blood  picture  was  complicated  by  the  occurrence  of 
infection,  for  whicli  n-.-ison  the  figures  are  not  given. 

That  interference  with  the  portal  circulation  inflow 
from  organs  other  than  the  spleen  may  cause  changes  in 

TABLE  XXX \  111 
13loi)d  Chanue:*  Following  Kck  Fistula 


•2    j                     1    H»moly5iJ* 

O 
J3 

4 

..a 

0, 

d 

J5 

^       Red  blood 

&E 

E 

iS 

Dog  31 

w         celU  per 

C  if 

""   BE 

c 

*« 

g     t      cmm. 

Com- 

= s 

?.i 

—  s 

ffi 

a 

J3 

* 

Begins 

plete 

Sg. 

"o  3 

86"^ 

1 

X 

_>j^ 

b. 

w 

- 

per 
cent. 

hlo$. 

Before 

99 

0,500,000  0.45 

0.325 

13,200 

9,800 

2,700 

500 

200  16.1 

1  (lay  after 

SS 

0,040,(X)0  0.475 

0.325 

36,0(JO  32,400 

2,800 

800| 

0     t 

3  days  after 

84 

6,300,000  0.45 

0.325 

32,4t)0  27„500 

2,tHX) 

1,000 

400   14.2 

5  clays  after 

72 

5,40().(KX)  0.425 

0.3 

24,0(M)17,;iO<> 

3,800 

2,400 

.500   14.2 

1  week  after 

74 

5,500,000  0.425 

0.3 

18,80013,700 

3,400 

800 

900   13.6 

2  weeks  after 

()8 

5,040,(X)0  0.425 

0.275 

19,60015,500 

3,900 

000 

600   13.5 

3  weeks  after 

73 

5,110,0(X)  0.425 

0.275 

i 

1 

4  weeks  after 

67 

4,460,000  0.425 

0.3 

21,00015,500 

4,400 

000 

.500  14.6 

5  weeks  after 

72 

4.8.80,000  0.475 

0.32.5 

18,400 

12,900 

3,700 

6(>0il,200   14.2 

6  weeks  after 

84 

5,600,000  0.475 

0.325 

16,000 

10,500 

3,800 

400:1,300   14.9 

7  weeks  after 

90 

6,200,000  0.45      0.3 

15,200  10,300 
15,80011,400 

2,800     t)001,.500;  15.3 

8  weeks  after 

98 

6,520,0(X)  0.45      0.3 

3,500 1    300 

600;  15.4 

*  The  figurt'9  in  these  columns  indirate  the  pcrrentaKPs  of  salt  solution  in  which  hemolysis 
was  6rat  noticed  and  in  which  hEemoljsis  first  became  complete. 

the  blood  is  shown  in  another  experiment  (see  Table 
XXXIX)  in  which  the  inferior  mesenteric  \ein  was  anas- 
tomosed with  the  vena  cava. 

This  dog  developed  an  anaemia  of  mild  grade  and  re- 
covered from  it  sooner  than  did  the  other  dogs  of  this  series. 
Although  little  weight  can  he  placed  on  a  single  experi- 
ment such  as  this,  the  observation  tends  to  support  the 
theory  that  the  supply  of  portal  blood  to  the  liver  is  a 


CONTROL  EXPERIMENTS 


WJ 


factor  in  the  produc-tiuii  of  the  changes  we  have  obsened 
to  occur  after  splenectomy. 

From  these  ohsen-ations  the  following  conclusions  may 
he  drawn: 

1.  In  donrs  in  which  the  spknic  vein  has  been  ligated  or 
transplanted  into  the  inferior  vena  cava,  or  in  which  an 
Eck  fistula  has  been  made,  an  ana;mia  occurs  which  re- 

TAULE  XXXiX 

Blood  CHANOEa  Folluwino  Tkansi-lantation  of  Inferior  Mesenteric 
Vein.    Control  Kxpekiment 


Dog  55 


Before 

2  days  after  . 

3  days  after  . 
10  days  after. 

2  weeks  after 

3  weeks  after. 

4  weeka  after. 
■)  weeka  after, 
ti  weeks  after. 


Hsemu- 

Ucil  Lluod  rells 
p«r  cmm. 

ilOMilO 

lysis  • 

gtobin 

Weight 

Begioa 

Cumplete 

per  cent. 

kilo$. 

100 

5,940,000 

0.45 

0.3 

14.7 

76 

o,240,(KX) 

0.4 

0.25 

75 

5,10(J,(H)0 

0.4 

0.25 

13.9 

7(j 

4,S.S0,000 

0.45 

0.275 

85 

5,400,000 

0.425 

0.25 

84 

5,S90,(X)0 

0.425 

0.25 

78 

5,600,000 

14.7 

88 

5,720,000 

92 

5,800,000 

0.425 

0.275 

15.3 

-..  fi  J,\^  'i*"T  '" '.hesc  rnlumn'<  indicate  the  perrpntsup.H  of  salt  solution  in  whirh  hemolysis 
wag  first  noticed  and  in  which  hjemulysis  first  became  complete.  u'oiyi 

sembles  that  following  splenectomy  and  shows  the  same 
general  variations  in  degree  and  duration. 

2.  The  resistance  of  the  red  cells  to  hypotonic  salt  solu- 
tion is  quickly  increased,  sometimes  coincident  with  and 
sometimes  preceding  the  anaemia.  It  gradually  returns  to 
normal  in  about  the  same  length  of  time  as  it  takes  the 
anfcmia  to  di.sappear,  differing  in  this  particular  from 
the  results  after  splenectomy. 

3.  There  is  an  initial  leucocytosis,  involving  at  first 
the  polymorphonuclear  leucoc^-tes  and  transitional  cells. 
As  the  total  leucocytosis  diminishes  there  is  both  a  relative 


1 1 


,^. 


130 


THE  SPLEEN  AND  ANJiML\ 


and  actual  incrcahc  of  small  lymplu>cytes  and  usually  also 
(.r  eosiuophilcs.  This  may  either  he  temporary  or  last 
during  the  rest  of  the  period  of  ohservation,  and  thus 
differs  from  the  ordiriaiy  postoperative  leueocytosis. 

4.  Ligation  of  the  splenic  vein  is  followed  hy  consid- 
erahle  atrophy  of  the  spleen,  hut  not  hy  necrosis  or  throm- 
bosis. There  is  rarely  adecjuate  new  vein  fonnation.  The 
other  operations  cause  little  or  no  change  in  the  spleen. 

.5.  \Vhether  the  disturbances  described  are  due  to  the 
loss  of  a  certain  volume  of  blood  to  the  liver,  or,  as  has 
been  previously  suggested,  to  the  loss  of  a  splenic  1  ormone 
acting  on  the  ha-mopoietic  tissues,  it  is  impossible  to  say. 
If  due  to  the  former,  the  method  of  production  of  the 
ana?mia  still  remains  unexplained.  It  is  evident,  also,  that 
the  latter  theory  has  no  value  uidess  it  is  assutned.  also, 
that  the  supposititious  hormone  normally  is  activated  by 
passage  through  the  liver. 

RESISTANCE  TO  HEMOLYTIC  AGENTS 
In  the  previous  pages  has  been  discussed  the  effect 
upon  the  blood  picture  of  tliree  methods  ( transplantation 
of  the  splenic  vein  into  the  vena  cava,  Eck  fistula,  and 
ligation  of  the  splenic  vein)  of  diverting  the  splenic  blood 
from  the  liver.  It  now  remains  to  present  the  res\dts  of 
a  study  of  the  influence  of  these  procedures  on  the  action 
of  hjrmolytic  agents.  Do  they  bring  about  a  decreased 
tendency  to  jaundice  when  a  ha?molytic  agent  is  given  and 
retard  the  repair  of  an  artificially  produced  anaemia,  as  is 
the  case  in  splenectomizcd  animals? 

As  ha-mohiiic  agents  we  have  employed  both  toluylene- 
diamine  and  ha?molytic  immune  senmi.  The  Iwmolytic 
senun  was  prepared  by  injecting,  at  regular  intervals,  the 


CONTROL  EXPERIMEN'I^ 


131 


erythicK.'vt.e.s  of  the  do^  into  rabbits.  All  injections  of 
strum  so  prepared  were  made  intravenously  into  the  do^. 
Merck's  nieta-toluylenediamine  was  given  by  stomach-tube, 
and  in  adequate  doses  never  failed  to  cause  anaemia  and 
jaundice.  In  each  experiment  the  control  animal  received 
the  same  proportionaiie  amount  of  dru^  or  serum  per  kilo, 
of  l)fMly  weight  as  did  the  test  animal.  Dogs  of  approxi- 
mately the  same  size  were  selected,  and,  on  account  of  the 
occasional  necessity  of  catheterization,  female  dogs  were 
used  whenever  available.  Splenectomized  as  well  as  nor- 
mal animals  were  included  in  the  series  tf)  further  com- 
parison with  our  previous  results.  Daily  and,  later,  weekly 
examinations  of  urine  and  complete  blood  examinations 
( including  resistance  of  erythrocytes  to  hvpotonic  salt  solu- 
tion) were  made  and  records  of  weight  were  kept.  Each 
animal  was  studied  as  to  condition  of  urine  and  blood  be- 
fore the  experiment.     Both  cage  urine  and  catheterized 

TABLE  XL 
Jaundice  After  Administration-  of  Toi.uTLENEDiAunN  (0.34  Gm.  Per  Kilo.) 


D..K  71 

Don  "9 

Dog  51 

- 

Splenic  vein  trans- 

Sploneoiomv 

Do«  75 
NorniaT  control 

Time  aftpr 
admiaistratioQ 

plant  <2  mo8.) 

(I'i  moa.) 

(2  mo«  ) 

0  42.')  B    H- 

0  40  B.  H  - 

0.4.5  B.  H.- 

0  42«  B    H 

(1  32.5  C.  H.* 

0  275C    H. 

0  275  C.  H. 

0  27.5  C    H 

No  ^.nemia 

No  an»mi:i 

.flight  anemia 

No  an»mia 

Before 

Urine  normal 

Urine  normal 

t'rine  normal 

I'rine  normal 

1  day  after 

Bile  trace 

Bile  slight 

Bile  moderate 

Bile  marked 

3  days  after 

Hile  heavy  trace 

Bile  slighi 

Bile  moderitr 

Bile  marked 

5  days  after 

Bile  trace 

Bile  moderate 

Bile  moderate 

Bile  marked 

7  da>'s  after 

Bile  absent 

Bile  moderate 

Bile  moderate 

Bile  marked 

9  da>-8  after 

Bile  absent 

Bile  moderate 

Bile  moderate 

Bile  moderate 

1 1  daj-s  after 

Bile  absent 

Bile  trace 

Bile  faint  trace 

Bile  trace 

13  days  after 

Bile  aljsent 

Bile  trace 

Bile  absent 

Bile  trace 

15  da\'s  after 

Bile  absent 

Bile  trace 

Biln  absent 

Bile  trace 

17  da>-8  after 

Bile  absent 

Bile  absent 

Bile  absent 

Bile  absent 

*  Thi§  space  in  this  and  following  tables  refers  to  the  condition  of  the  blood  before  beinnnlng 
the  eiperimenl  The  finures  inriiciite  strenrth  nf  salt  solution  at  which  hffmolvsis  occurs; 
B  H  indicates  beirinnine  hrmolvsis.  C.  H.  complete  hfpmolvsis.  Increasing  amounts  of  bile 
in  the  unne  are  expressed  in  the  following  terms;  faint  trace,  trace,  h»avy  trace.  Blight,  moderate, 
marked. 


'$m 


If '" 
^1  i; 


132 


THE  SPLEEN  AND  AN.EMIA 


specimens  (in  doubtful  cases)  were  examined,  and  the 
presence  of  bile-pij^ment  in  the  urine,  determined  by 
Gmelin's  and  Rosenbach's  tests,  was  taken  as  the  surer  . 
evidence  of  jaundice.  At  the  termination  of  the  experi- 
ment tlie  animals  were  sacrificed  in  order  to  determine  the 
exact  anatomical  disturbance  caused  by  the  operation. 

As  may  be  seen  in  Table  XL,  in  all  animals  receiving 
toluyknediamine,  control  as  well  as  experimental,  some  bile 
appeared  in  the  urine.  The  bile  was  less  in  amount,  how- 
ever, and  lasted  for  shorter  periods  in  the  test  animals  than 
in  the  normal  controls.  In  fact,  animals  with  the  vein 
transplant  and  Eck  fistula  showed  even  less  tendency  to 
jaundice  than  the  splenectomized  animal. 

TABLE  XLI 
Jaundice  After  Administration  of  Toluylenediamin  (0.13  Gm.  Per  Kilo.) 


— ^-;- 

Don  OK 

DoK  ss 

Dog  77 

Eck  fintula 

MpFienterii-  vein  trans- 

Nornial control 

Time  after 

(1  mo.) 

plant  (1  'j  mos.) 

No  anffniia 

administralion 

0.4  H.  H  -<)275C.  H. 

0.4:^5  B   H.-O  27.'--  C.  H. 

0.425  B.  H.-O  35  C.  H. 

Anaruia  prcsenl 

No  anten-.ia 

Before 

Ifriiie  normal 

I'rine  normal 

Urine  normal 

1  dav  after 

Hile  absent 

Bile  trace 

Bile  trace 

2  davs  after 

Hile  faint  traee 

Bile  trace 

Bile  marked 

3  davs  after 

Uile  faint  trace 

Bile  ni(Hlerat;e 

Bile  moderate 

5  days  after 
7  days  after 
9  days  after 

Hile  absent 

Bile  doubtful 

Bile  moderate 

Hile  absent 

Bile  al)sent 

Bile  trace 

Bile  absent 

Bile  absent 

Bile  absent 

Another  experiment  (see  Table  XLI)  in  which  a 
smaller  single  dose  was  administered  gave  similar  results. 
It  was  in  this  experiment  that  the  animal  that  was  sup- 
posed to  have  had  the  splenic  vein  transplanted  was  found 
at  autopsy  to  have  a  brancli  of  the  inferior  mesenteric  vein 
transplanted  ])y  mistake,  thus  unwittingly  causing  an  excel- 
lent double  control  for  the  Eck  fistula  test  (No.  68) .  The 
increased  resistance  to  jaundice  of  this  dog  (No.  55)  as 


CONTROL  EXPERLMENTS  iss 

compared  to  the  normal  (Xo.  77)  is  still  further  evidence 
ol  the  importance  of  the  mechanical  factor  of  blood  supply 
to  the  liver. 

In  a  third  experiment  in  which  three  smaller  repeated 
doses  of  toluylenediaminewere  given  to  animals  with  splenic 
vein  transplant  and  splenic  vein  ligation  and  to  a  normal 
control  these  results  were  confirmed.  The  vein  transplant 
dog,  though  his  red  cells  at  the  time  were  the  least  resistant 
of  the  three,  failed  to  develop  jaundice;  the  other  two  did. 
The  jaundice  in  the  ligation  experiment,  however,  lasted 
three  days,  and  that  of  the  control  nine  days. 

In  the  experiments  with  hemolytic  immune  serum  the 
same  results  were  obtained.    In  a  i.eliminary  experiment 

TABLE  XLII 
Jaundice  After  Admini8tration  of  H^moi  ytic  Sercm  (Sercm  No  3  0  4  c  c 

Per  Kilo.)  ' 


Time  Kfter 

,     Do(t4 
Vein  twitch 
(2  mo8.) 

Dog  2 
npiriiectomy 

(2ia  mos.) 

^^      Dog  25 
Normal  control 

0.40  B.  H.-0  325C.  H. 
Slight  aniemia 

0.425  B.  H.-0.25  C.  H. 
Slight  antemia 

0.475  B.  H  -fl  35  C.  H. 
No  ancemia 

Before 
1  day  after 
~  days  after 
4  days  after 
()  days  after 

Urine  normal 

No  bile 
No  bile 
No  bile 
No  bile 

Urine  normal 
Bile  moderate 
Bile  moderate 
Bile  moderate 
Bile  absent 

Urine  normal 
Bile  trace 
Bile  moderate 
Bile  absent 

with  three  animals,  in  which  large  doses  of  senim  were 
given,  the  Eck  fistula  dog  alone  survived  and  developed 
jaundice;  one  with  vein  transplant  and  also  a  normal  con- 
trol  died  in  a  few  hours;  the  control,  ho-vever,  had  already 
developetl  hamioglobinuria,  whereas  the  vein  transplant 
dog  failed  to  develop  either  hcTmoglobinuria  or  jaundice. 

With  a  weaker  serum  (see  Table  XLII)  the  greater 
resistance  of  the  vein  transplant  animal  is  shown.    A  result 


11 


* 


134  THE  SPLEEN  AND  AN.EMIA 

contrary  to  our  former  experienc.-s  was  obtained  in  this 
experiment,  in  that  No.  2  (splenectomized)  developed  as 
severe  a  jaundice  as  did  tlie  control. 

In  another  experiment  (see  Table  XLIII)  '.'le  same 
instructive  results  were  obtained  with  a  serum  of  less  ha^mo- 
lytic  power. 

TABLE  XLIII 
Jaundke  After  Admimstkation  of  H.KMoi.-iTic  Serum  (Perim  No.  3,  0.2  c.c. 

Per  Kilo.) 


Time  altfr 
admiaidt  ration 

Dog  h> 

Vein  transplant 

^occluii«'*i  vesHcl.*) 

(1  uio.) 

Don  1 
SpW'nectora> 

(;j  nu)3  1 

Dog  51                       j5„    27 
Ligation              Normal  control 

(t»  nios  ) 

OiB   H- 

0  2.^1  C    H. 
.\Q»naa  pre.sfnt 

0.4  B.  n  - 

().i!.5  C    H. 

Slight  aneemia 

0  45  B    H.- 
0.a25  C.  H. 
No  anemia 

O.lj  B   H  - 
0  35  C    H 
No  anffmis 

Before 
1  day  aftor 
?  days  after 
3  days  after 
5  days  after 

Irine  normal 
No  bile 
No  bile 
No  bile 
No  bile 

Irine  normal 
No  bile 
No  bile 
No  bile 
No  bile 

Trine  normal 
No  l)ile 
Bile  marked 
Bile  marked 
Bile  marked 
(Bile  still  pres- 
ent   on     the 
14th  day) 

I'rine  normal 
Bile  marked 
Bile  moderate 
Bile  trace 
Bile  absent 

As  the  transplanted  splenic  vein  of  No.  16  was  found 
at  autopsy  to  have  been  occluded  by  a  comparatively  recent 
thrombus  (probably  antedating  the  administration  of 
serum),  this  exj)criment  must  be  -egarded  as  analogous 
to  a  ligation  experiment.  The  relatively  slight  tendency 
to  jaundice  in  this  animal  as  compared  with  No.  51  may 
be  largely  explained  by  the  greater  resistance  of  the  red 
cells  in  the  former  animal. 

The  results  of  these  experiments,  while  somewhat  dis- 
cordant, indicate  that  the  mechanical  factor  of  the  method 
of  the  blood's  approach  to  the  liver  is  of  importance  in  de- 
termining the  degree  of  jaundice  after  the  administration 


CONTROL  EXPERIMENTS 


135 


of  haemolytic  agents.  Our  results  in  this  regard  are  in 
accord  with  those  obtained  in  our  comparative  studies  of 
the  effect  of  injecting  ha?nioglobin  into  the  portal  as  con- 
trasted with  the  general  circulation  (see  page  64). 

The  interpretation  of  the  severity  and  duration  of  the 
anipniia  caused  in  the  various  test  animals  is  complicated 
by  several  factors.  In  the  first  place,  the  original  operation 
iiecessar}'  to  produce  the  venous  anastomosis  has  been 
sliown  to  cause  anaemia.  As  the  test  animals  were  some- 
times given  the  hjemolytic  agent  while  more  or  less  ana?mic, 
we  have  had  to  analyze  our  results  with  constant  reference 
to  this  factor.  Moreover,  we  have  found  that  in  most  cases 
the  severity  of  the  anfcmia  largely  parallels  the  resistance 
of  the  red  cells.  In  some  cases,  however,  animals  with  the 
most  fragile  cells  develop  the  least  anaemia  after  adminis- 
tration of  ha?molytic  agents.  Changes  in  weight  in  the 
animals  of  these  experiments  seem  to  liear  no  definite 
significant  relation  to  the  anaemia. 

We  have  previously  stated  "'  that  "  the  anfemia  caused 
in  splenectomized  animals  by  h^moh-tic  agents  is,  as  shown 
by  direct  blood  examination,  of  greater  severity,  nms  a 
longer  course,  and  has  a  longer  period  of  repair."  By 
greater  severity  was  meant  that  the  haemoglobin  and  red- 
cell  count  reached  lower  figures  than  in  the  control.  The 
actual  blood  destruction,  however  (if  determined  by  esti- 
niating  the  change  from  the  condition  immediately  before 
administering  ha-molytic  agents),  was  usually  less  in  sple- 
nectomized than  in  normal  dogs.  Oiar  experiments  of  this 
year  show  that  the  same  statements  hold  true  after  trans- 
plantation of  the  splenic  vein  into  the  vena  cava,  Eck 
fistula,  and  ligation  of  the  splenic  veins. 

The  actual  blood  destruction  of  the  test  animals  has 


I 


i- 


\-\n 


136 


THE  SPLEEN  AND  AN.EAUA 


i?v 


been  constantly  less  tlian  in  the  normal  controls,  and  in  a 
few  instances  even  the  degree  of  ansemia  as  expressed  by 
the  hicnioglobin  and  red-cell  count  was  less  severe  in  the 
test  animals.  As  a  constant  feature,  the  greater  severity 
of  the  anaemia  nmst  therefore  be  considered  as  open  to 


TABLE  XLIV 

DURATKIN   AND  SEVERITY   OF  A>f.EMIA   AfTER  ADMINISTRATIO^f  OP    ToLUYLENE- 

DiAMi.v  (0.34  Gm.  Per  Kilo.)* 


Time  after 
sdministratiou 


Before 

1  day  after 

3  days  afferi 

5  days  after' 

7  days  after 

9  days  after 

12  days  after 

16  days  after 

22  days  after 

29  days  after, 

35  days  after 

41  days  after 

49  davs  after 


Time  after 
odminiatration 


DogTl 
Splenic  vein  transplaDt 


98 


Red  blood 
celL^ 


6,785,000 
6,940,000 
5,400,000 
5,340.000 
4,820,000 
5,070,000 
5,8',)O,0OO 
6,210,000 
6,350,000 


6,800,000 


Resistance 


B.  H.  C.  H. 
0.45  -0.325 
0.5  -0.3 
0.475-0.275 
0.475-0.325 
0.475-0.325 
0.5  -0.3 
0.5     -0.3 

0.5     -0.3 

0.5     -0.3 
0.475-0,325 


Dog  79 
Splenectomy 


Hiemo- 
globin 


per  cent. 

74 

84 
60 
43 
62 
63 
66 
69 
68 
76 
88 
88 
92 


Red  bIt>od 
cells 


Resistance 


5,720,000 
4,770,000 
4,250,000 
3,380,000 
3,820.000 
4,080,000 
4,.320,0(X) 
4,530,000 
4.510.000 
5,2,80,000 
5,5i)0,000 
5,480,000 
5,680,000 


'   B.  H.     C.  H. 

i  0.4     -0.275 

:  0.5     -0.275 

I  0.426-0.275 

0.45  -0.25 

i  0.45  -0.25 

0.425-0.25 

0.425-0.25 


0.4 
0.4 
0.4 
0.4 
0.4 


-0.275 

-0.25 

-0.275 

-0.35 

-0.25 


Before 

1  day  after 

3  days  after 

5  days  after 

7  days  after 

9  dpys  after 

12  days  after 

16  days  after 

22  davs  after 

29  days  after 

35  days  after 

41  days  after 

49  days  after 


Hsenio- 
globin 


Dog  81 
Ligation 

Red  blood    1 


Dog  75 
Normal  control 


pfT  rent. 

80 
90 

60 


4,020,000 
4,.S0O,000 


Resistance 

B.  II.  c  n 
0.45  -0.275 
0.5     -0.325 


3,820,000    0.375-0.25 


0.45  -0.3 
0.45  -0,275 


62 

3,3101)00 

65 

3,9S(),(M)0 

72 

4,320,000 

74 

4,6.50,000 

7() 

4,0.'j(),(>i»<) 

84 

5,330,000 

78 

5,340,000 

87 

5,550,000 

0.475-0.35 

0.425-0.3 
0.45  -0.3 


HBmc ' 
frlobin 

Red  blood 
cells 

Resistance 

per  cent. 

B  //,     C.  II. 

85 

6,180,000 

0.42.5-0.275 

96 

5,080,000 

0.45  -0.35 

48 

4,590,00*1 

0.47.5-0.275 

38 

2.980,000 

0.45  -0.3 

45 

3,6.30,000 

0.475-0.3 

55 

3,930,000 

0.45  -0.3 

68 

4,800,000 

0.47.5-0.3 

SO 

5,200.000 

0.475-0.3 

85 

6,820,000 

0.425-0.3 

*  TliL-   fiiiurf^a  in   (lie  onluinii!!    "UewiMtanrf^"    indiratp    the  perreotages  of  salt  sotutioo  at 
which  hemolysiB  waa  tirat  noticed  and  first  became  complete. 


CONTROL  EXPERLMENTS  137 

question,  while  the  actual  blood  destruction  in  the  test  ani- 
mals is  undoubtc-dlj  less  than  in  the  normal  controls. 

The  dui-ation  of  the  anemia  of  the  test  animals  has 
been  longer  than  that  of  the  normal  controls  and  paralleled 
that  of  the  splenectomy  controls.  The  difference,  how- 
oxer,  of  both  test  and  splenectomy  dogs  from  the  normal 
controls  has  been  less  striking  than  in  our  previous  work, 
and,  like  the  variable  degree  of  anaemia  after  splenectomy,' 
Miust  be  referred  to  variations  in  unknown  factors  (pos- 
sibly such  as  diet,  or  differences  in  toxicity  of  the  serum). 

An  experiment  with  tohiylenediamine  showing  the  char- 
acter of  the  blood  repair  after  various  forms  of  experi- 
mental disturbance  of  splenic  function  is  seen  in  Table 
XLIV. 

TABLE  XLV 

DnRATION    AND  SeVERITT   OF  An.^JHA    ApTER  AdMINISTOATION     of    H^MOLTTIC 

Sercm  (0.4  cc.  Per  Kilo.) 


Time  sfter 
administration 


Dob  4 

Vein  transplant 

(2  mos.) 


ring  2 

yplenertomy 

(3;-5  nioa.) 


Before 
1  day  after 
6  days  after 
10  days  after 
I  ()  days  after 
19  days  after 
liO  daj's  aft«r 
■i  1  daj  a  af t«r 


Hffmo- 

dlobin 

prr  cent. 
97 

83 
6,5 
62 
70 
90 
96 
102 


Red  blood 
rella 


6,960,000  i 
4,840,000 
3,940,000 
3,750,000  i 
4,390,000  i 
5,060,000  I 
6,010,000 
6,400,000  I 


Hffimo- 
globin 

per  cent. 
85 
78 
55 
67 
67 

78 
82 


Ued  blood 
cell* 


4,950,t00 
4,920,000 
3,670,0<X) 
3,890,000 
4,090,000 

5,260,000 
5,590,000 


Don  25 
Normal  control 


H«mo-     !    Re<l  blood 


Klobin 


per  cent. 
102 
82 
58 
78 
80 
93 
106 


cella 


6,400,000 
5,040,000 
3,950,000 
4,480,000 
4,880,000 
5,490,000 
6,060,000 


In  a  second  experiment  the  red  cells  of  an  Eck  fistula 
animal  dropped  one  million  less  than  the  control,  but  took 
two  months  to  return  to  normal  level,  as  opposed  to  nine- 
teen days  m  the  control.  In  a  third  experiment  .smaller 
doses  of  serum  failed  materially  to  affect  the  blood  picture 

A  similar  experiment  with  ha?molvtio  immune  serum 
IS  presented  in  Table  XLV. 


ii 


flii 


188 


THE  SPLEEN  AND  ANJiMIA 


In  another  experiment  a  weaker  serum  failed  to  cause 
anaemia  in  a  splenectomized  dog,  as  well  as  in  one  with 
occluded  splenic  vein  transplant:  however,  an  animal  with 
ligated  splenic  vein  developed  ahout  the  same  amount  of 
anicmia  as  the  control,  but  took  a  nmch  longer  time  to 
recover. 

Behavior  of  Leucocytes. — Botlitoluylenediamine  and 
ha'molytic  inmiune  serum  cause  a  marked  leucocytosis, 
which  reaches  its  height  in  one  to  three  days  and  lasts 
two  to  four  weeks.  The  first  and  greatest  rise  (actual  and 
relative)  is  in  the  polymorphonuclear  and  transitional  cells; 
this  is  later  followed  by  a  less  marked  and  more  persistent 
rise  of  small  lymphocytes  and  eosinophiles.  There  was 
no  essential  difference  in  the  reaction  of  the  test  dogs 
and  their  controls,  except  that  the  latter  were  affected 
by  doses  too  small  to  influence  the  former.  These  changes 
resemble  those  previously  described  as  following  the  vari- 
ous operative  procedures  on  the  spleen,  and  probably  indi- 
cate a  general  rather  than  any  specific  interference  with 
the  leucocytic  elements  of  the  blood. 

From  these  obser\'ations  the  following  tentative  con- 
clusions may  be  drawn: 

1.  Dogs  whose  splenic  vein  or  portal  vein  (Eck  fistula) 
has  been  transplanted  into  the  inferior  vena  cava,  or  whose 
splenic  veins  have  been  ligated,  develop  a  lessened  tendency 
to  jaimdice  similar  to  that  exhibited  by  splenectomized 
animals. 

2.  Although  the  previously  existing  anffmia  and  the 
concomitant  increased  resistance  of  the  red  cells  of  these 
animals  are  undoubtedly  factors  in  the  greater  resistance 
to  hfemoh^ic  agents,  the  lessened  tendency  to  jaundice  is, 
In  part  at  least,  due  to  a  mechanical  factor  dependent  on 
the  change  in  the  bloof]  supply  to  the  liver. 


CONTROL  EXPERIMENTS 


139 


3.  The  additional  anaemia  caused  in  the  test  animals  by 
hcPmolj-tic  agents  is  usually  less  than  in  the  controls,  al- 
though the  total  fall  from  the  original  normal  may  be, 
and  usually  is,  greater  than  in  the  control.  This  applies 
to  the  splenectomized  as  well  as  the  other  test  animals  of 
these  experiments. 

4.  Although  the  destruction  of  blood  in  these  animals  is 
less  than  in  the  controls,  the  repair  of  the  same  takes  con- 
siderably longer  than  in  the  controls.  This  confirms  sim- 
ilar results  previously  obtained  in  splenectomized  animals. 

5.  The  white  cells  exhibit  much  the  same  changes  as 
follow  the  administration  of  hjemolytic  agents  to  splenecto- 
mized or  normal  animals.  As  these  changes  are  not  unlike 
those  following  uncomplicated  splenectomy  or  the  opera- 
tions here  discussed,  they  cannot  be  considered  as  char- 
acteristic of  any  of  the  above  procedures. 


CHAPTER  VI 

THE  CHANGES  IN  THE  BONE-MARROW  AFTER 
SPLENECTOMY 

(i)  DISCUSSION  OF  THE  LITERATURE,  (2)  HISTO- 
LOGICAL STUDIES  OF  THE  DOG'S  NORMAL  MAR- 
ROW, (3)  CHANGES  AFTER  SPLENECTOMY 

In  many  instances  we  have  examined  ^^"  the  bone- 
marrow  of  splenectomized  dogs  with  a  view  to  determinin<jf 
the  compensatory  or  other  changes  following  the  removal 
of  the  spleen.  The  material  at  our  disposal  consists  of 
marrows  representing  periods  varying  from  a  few  days  to 
twenty-two  months  after  splenectomy. 

In  the  literature  of  the  subject  the  reference  to  changes 
in  the  bone-marrow  following  splenectomy  are  for  the  most 
part  casual  and  presented  but  incidentally  in  connection 
with  the  associated  changes  in  the  lymph-  and  ha-molymph- 
glands.  In  Warthin's  ■"''  collection  of  the  literature  up  to 
1903  the  following  references  occur: 

Tizzoni  and  Fileti  *•"'  (1880)  and  Tizzoni ''"'  (1882) 
observed  in  splenectomized  dogs  a  transformation  of  the 
fatty  marrow  of  long  bones  into  red  marrow. 

Mosler^"^  (1882),  working  likewise  with  dogs,  con- 
cluded that,  following  splenectomy,  there  may  be  com- 
pensatory action  on  the  part  of  both  lymph-glands  and 
bone-marrow,  the  latter  appearing  to  play  an  important 
role.  In  one  animal  the  bone-marrow,  ten  months  after 
splenectomy,  resembled  that  of  leukaemia.  This  change, 
however,  was  not  constant. 

Laudenbach -^°   (1893)   observed  in  one  dog,  ten  to 

140 


(  HANGES  IN  BONE-MARROW 


141 


twelve  years  of  agt,  with  severe  anteniia,  signs  of  increased 
blood  formation  in  the  marrow  145  days  after  splenectomy. 
Ceresole""  (1895),  on  the  other  hand,  found  in  sple- 
nectomized  rabbits  no  clearly  defined  new  formation  of  the 
marrow. 

Warthin*«'  ((1903)  states  that  after  splenectomy  in 
the  sheep  and  goat  slight  lymphoid  changes  in  the  fatty 
marrow  occur,  hut  gives  no  detailed  histological  descrip- 
tion. Of  these  changes  he  says:  "The  beginning  lym- 
phoid changes  in  the  fatty  bone-marrow  in  the  second  and 
fifth  months  after  splenectomy  is  to  be  regarded  as  com- 
pensatory only  for  the  increased  destruction  of  red  blood- 
cells  and  not  for  any  abrogated  splenic  function  of  red-cell 
formation." 

Other  references  may  be  found  to  changes  in  the  bone- 
marrow  in  the  presence  of  diseases  of  the  spleen  in  man  and 
in  experimental  ansmias  of  animals  with  or  without  sple- 
nectomy, but  few  findings  after  simple  removal  of  the 
normal  spleen  are  available.  Among  the  latter  are  Pug- 
liese's  ^"^  observation  that  after  total  splenectomy  the  bone- 
marrow  of  the  hedgehog  becomes  filled  with  giant-cells. 
This  change  Foa  "°  has  not  found  to  be  characteristic  of 
the  rabbit.  Vulpius,**"  who,  in  1894,  reviewed  thoroughly 
the  subject  of  the  surgery  and  physiologj-  of  the  spleen, 
and  adds  some  experimental  observations,  supports  the 
theory  of  increased  activity  of  the  bone-marrow  after  sple- 
tiectomy.  Winogradow  *"  found  red  marrow  in  the  long 
bones  of  a  dog  132  days  after  splenectomy,  but  yellow 
marrow  was  present  in  two  after  517  and  760  days  respec- 
tively, though  one  of  the  latter  was  slightly  streaked 
with  red. 

Hodenpyl,'*"  in  the  description  of  a  case  of  absence 


til 

in 


142 


THE  SPLEEN  AND  AN.EMU 


of  the  spleen  Im  man  makes  no  mention  of  the  bone-marrow, 

Taylor  ^^^  desorihcs  the  marrow  of  two  splenectomized 
(logs:  that  from  an  animal  receiving  alhumoses  by  mouth 
and  by  hypodermic  injection,  and  killed  after  nine  months, 
was  red;  a  second,  not  receiving  alhumoses,  shewed  a  yellow 
marrow  at  the  end  of  one  year. 

Freiberg  '■-■"  states  that  he  found  red  marrow  in  sple- 
nectomized animals,  and  Gibson  '^"  notes  that  in  a  dog 
killed  five  and  a  half  months  after  being  deprived  of  the 
spleen  the  marrow  was  apparently  in  the  process  of  change 
from  yello     to  red. 

In  some  of  these  accounts  brief  mention  is  made  of  the 
increase  of  giant-cells  or  of  pigmented  cells  or  of  the 
numerical  relations  between  the  myelocytes  and  the  white 
and  red  cells,  but  we  have  l)een  unable  to  find  an  adequate 
account  of  the  histolog}'  of  the  bone-marrow  after  splenec- 
tomy based  on  modern  conceptions  of  the  cytology  of  this 
tissue.  Histologic  descriptions  exist,  but  they  are  either 
brief  and  fragmentary  or  are  based  on  views  current  before 
the  attainment  of  our  present  detailed  knowledge  of  the 
morphology  of  the  cells  of  the  blood. 

Methods. — Our  studies  are  based  chiefly  on  the  changes 
in  the  marrow  of  the  long  bones,  and  particularly  in  that 
of  the  femur.  As  this  marrow  in  the  adult  is  normally 
fatty,  objection  may  l>e  raised  against  its  use,  and  to  over- 
come this  objection  we  attempted  to  study  the  marrow  of 
the  compact  bones.  The  methods  of  decalcifying  tissues 
have,  however,  in  our  hands  failed  to  yield  satisfactory 
histologic  preparations.  The  alternative,  the  use  of  film 
preparations,  obtained  successively  at  intervals  over  long 
periods  of  observations,  being  impracticable,  the  study  of 
cover-glass  preparations  was  limited  to  a  single  observation 


CHANGES  IN   BONE-MARROW  143 

at  the  time  of  the  death  of  the  aiunial.  At  the  same  time, 
however,  in  many  instanees  marrow  squeezed  from  the 
rihs  has  been  obtained  in  sufficient  amount  to  section  and 
thus  to  allow  a  comparison  with  chancres  in  the  fatty  mar- 
row We  have,  however,  depended  lar^^ely  upon  the  study 
of  sections  of  the  marrow  of  the  lon^  bones,  and  in  par- 
ticular of  the  femur.  We  are  sati-fied,  as  the  result  of  our 
study  of  the  marrow  from  a  lar^e  number  of  normal  do^s. 
that  this  is,  after  all.  the  most  rational  method  of  studying 
compensatory  changes,  for  it  is  unusual,  even  in  a  definitely 
fatty  marrow,  not  to  find  numerous  centres  of  blood-form- 
ing? cells.  These  may  be  limited  to  the  periphery'  of  the 
marrow  or  be  scattered  throughout,  but,  whatever  their 
position,  they  afford  an  excellent  starting-point  for  the 
study  of  increased  cellular  content,  as  well  as  of  changes 
in  the  character  of  the  cells.  The  fatty  marrow  is  of 
especial  value  in  the  study  of  the  late  changes,  for  in  well- 
fixed  and  well-stained  marrow  there  can  be  no  doubt  about 
the  change  from  a  purely  fatty  marrow  to  a  red  marrow 
rich  in  cells.  This  is  so  striking  as  to  remove  all  the  doubt 
which  exists  when  one  examines  the  marrow  of  compact 
bone,  as  of  the  ribs  or  vertebne,  by  either  the  section  or 
cover-glass  method. 

We  have  worked  exclusively  with  the  marrow  of  the 
middle  third  of  the  femur,  avoiding  the  marrow  at  either 
end,  partly  on  account  of  its  bony  nature,  but  chiefly  be- 
cause of  the  occasional  normal  occurrence  of  more  or  less 
red  marrow  at  the  ends  of  the  shaft.  As  onlv  adult  dors 
have  been  used,  we  feel  that  the  constant  use  of  the  middle 
portion  of  the  marrow  gives  fairly  comparable  results. 
In  remo%nng  the  marrow  half  the  circumference  of  the 
bone  through  the  greater  part  of  its  length  has  been  chipped 


144 


THE  SPLEEN  XSD  AN^MLV 


away,  aiid  alter  separating'  the  marrow  from  the  bone  and 
cutting  it  at  either  end  it  has  been  easily  removed  as  a  solid 
cylinder  by  gently  rolling  it  on  to  a  piece  of  filter-paper. 
In  carrying  these  tissues  through  the  process  of  fixation 
and  imbedding,  the  filter-paper,  which  is  firmly  adherent 
to  the  marrow  through  the  coagulation  of  the  attached 
blood,  allows  the  necessary  manipulations  without  injury 
to  the  marrow  itself.  The  routisie  procedure  has  been  to 
fix  in  Zenker's  fluid  without  previous  decalcification,  imbed 
in  paraf!ine,and  stain  with  eosin  and  polychrome  methylene 
blue.  Other  stains  have,  however,  l)een  used  whenever 
necessary  •::   bring  out  certain  details. 

Results. — It  may  be  stated  at  the  outset  that  we  have 
found  no  evidence  of  an  early  change  in  the  bone-marrow. 
Splenectomy  does  not  cause,  as  do  successive  hemorrhages 
and  hiemolytie  poisons,  a  rapid  change  of  fatty  marrow 
to  red  marrow.  This  latter  change  we  have  produced  read- 
ily and  rapidly  in  non-splenectomized  control  animals  by 
the  use  of  specific  lutmolytic  senmi  and  by  causing  hemor- 
rhage, but  we  have  never  seen  a  frank  change  from  yellow 
to  completely  red  marrow  in  the  ordinary  course  of  events 
in  the  splenectomized  animal  until  many  months,  usually 
six  or  more,  had  elapsed,  and  this  despite  the  fact  that 
many  of  the  animals  have  had,  as  has  been  sho>vn  in  our 
earlier  work,  a  moderately  severe  anaemia.  This  ana?mia 
has  frequently  been  of  as  severe  degree  as  that  caused  by 
several  successive  hemorrhages  in  the  normal  dog,  but 
changes  in  the  marrow  analogous  to  those  caused  by  hemor- 
rhage have  not  been  evident  in  the  earlier  periods  following 
splenectomy. 

In  this  connection  it  may  be  recalled  that  the  anamia 
of  splenectomy  in  the  dog  follows  a  gradual  downward 


CHANGES  L\  BONE-MARROW 


145 


course  for  three  to  six  weeks,  the  decrease  in  ha?mogl()bin 
lici/i>r  relatively  more  marked  than  the  decrease  in  red  cells, 
and  that  an  equally  gradual  repair  causes  the  red-cell 
count  and  hicmoglohin  content  to  approach  normal  after 
three  to  four  months  or  more.  At  the  same  time  th^re  is 
a  transient  initial  leucocytosis,  due  chiefly  to  polymor- 
phonuclear leucocytes,  and  some*^"mes  lymphocytosis  with 
a  late  eosinophilia.  Not  infrequently  the  eosinophiles  dis- 
ai)pear  from  the  circulating  blood  from  the  third  week  until 
the  end  of  the  third  month. 

We  have,  therefore,  in  the  course  of  our  studies  at- 
tempted to  determine  whether  the  hyperplasia  in  the  I  .le- 
uiarrow  after  splenectomy  is  compensatory  in  the  sense  of 
(1)  an  overactivity  in  red-cell  formation  chiefly,  (2)  over- 
activity in  the  formation  of  the  white  cells  chiefly,  (3)  an 
overactive,  orderly  reproduction  of  a  new  marrow,  with 
involvement  of  all  cells  arising  within  it. 

The  Xormal  Marrow  ok  the  Femur  of  the  Dog 
In  our  study  of  the  marrow  of  both  normal  and  sple- 
nectomized  animals  we  have  used  as  a  basis  for  orientation 
Bunting's  "''  conception  of  ciythrogenetic  and  leucogenetic 
centres,  Muir's  ^"^  descriptions  of  erythroblastic  arid  leuco- 
blastie  reactions,  and  have  received  also  much  aid  from 
Dickson's"''  study  of  the  cytology  of  marrow.  The  ar- 
rangement described  by  Bunting  is  by  no  means  a  constant 
and  definite  one,  but  in  the  masses  of  marrow  cells  may 
be  seen  groups  composed  mainly  of  myeloblasts  and  sur- 
rounded at  times  by  a  nearer  zone  of  myeloc>'tes  and  an 
outer  zone  of  leucocytes;  in  other  groups  with  the  same 
centre  the  outer  zone  may  be  made  up  of  nucleated  red 

cells,  with  a  still  more  distant  zone  of  normocytes.    We 
10 


«-  »=i| 


I 


146 


THE  SPLEEN  AND  ANEMIA 


are  not  convinced  that  centres  for  the  production  exclu- 
sively of  red  cells  or  of  white  cells  exist,  for  frequently  an 
intermingling  of  the  two  types  is  seen  in  one  centre,  but 
this  conception  of  definite  centres  is  of  great  assistance 
in  the  interpretation  of  marrow  changes. 

The  study  of  the  marrow  of  the  femur  from  many 
normal  dogs  has  led  to  our  recognition  of  four  definite 
groups  of  cells: 

1.  Groups  of  undifferentiated  cells  and  myelocytes. 
These  lie  between  fat  cells  and  seem  to  be  in  no  way  con- 
nected with  blood-channels.  In  all  these  centres  the  cells 
of  the  connective-tissue  reticulum  are  in  evidence. 

2.  Groups  of  the  character  described  above,  but  with  a 
peripheral  accumulation  of  cells  in  which  those  of  the  leu- 
cocytic  series  predominate. 

3.  Groups  as  in  (1 ) ,  but  with  a  mantle  of  cells  in  which 
those  of  the  erythrocytic  series  are  -rost  in  evidence;  and 

4.  Groups  as  in  (1),  but  with  an  indiscriminate  min- 
gling of  cells  of  red  and  white  series. 

These  groups  cannot  always  be  differentiated,  for  not 
infrequently  an  indiscriminate  mingling  of  cells  obscures 
the  recognition  of  centres.  Moreover,  at  times  may  be 
seen  groups  composed  purely  of  white  cel^s  or  of  red  cells 
without  myeloblastic  centres.  We  have,  however,  found 
that  search  for  the  groupings  described  |;ieatly  facilitates 
the  study  of  complex  marrow  pictures  and  leads  readily  to 
a  decision  as  to  whether  leucoblastic  or  erythroblastic  activ- 
ity predominates. 

In  one  respect  the  stiidy  of  normal  marrow  has  not 
helped  us  greatly,  ^regakarj-ocytes  and  polykaryocytes 
are  so  infrequent  in  the  normal  fatty  marrow  that  wo  have 
no  basis,  '^^  regard  to  them,  for  a  comparison  with  hyper- 


CHANGES  IN  BONE-MARROW  147 

plastic  marrow.  The  same  holds  true  for  the  large  en- 
dothelial cells  which  are  phagocytic  for  red  cells  and  are 
found  so  frequently  in  hyperplastic  marrow  to  contain 
remnants  of  red  cells  and  particles  of  pigment. 

The  Makrow  of  Splekectomized  Animals 
In  Table  XL VI  the  general  results  of  our  observations 
are  presented.    The  terms  "  yellow  "  and  "  red  "  refer  to 
the  gross  appearance,  not  of  the  surface  of  the  marrow, 

TABLE  XLVI 
Htperplabia  op  the  Marrow  op  the  Femur  After  Splenectomt 


Dog 

No. 


50 
23 
21 

f 

81 
17 
10 
39 
32 
44 
41 
24 
59 
57 
33 
51 


Period  after 
•pleaectomy 


24     dayu 

39  days 

40  days 


GroM 
appearance 


42 
60 

63 
84 


da., 
days 
daj-B 
days 


7 

inoniii 
monthsi 

8 

months 

O'i, 

rnonths 

10 

months 

1 

year 

m 

years 

m 

vears    ' 

m 

years 

u 

years 

Yellow 

Yellow 

Yellow 

Yellow 

Yellow 

Slieht  streaking 

bellow 

i{ed 

Red 

Yellow 

Yellow 

Yellow 

Red 

Red 

Streaked 

Red 

Yellow 


Microscopic 
change 


Slight 

88 

None 

88 

Slight 

65 

SL  4ht 

96 

Slight 

92 

Slight 

76 

Slight 

6C 

Complete 

78 

Complete 

68 

Slight 

97 

None 

81 

None 

92 

Complete 

110 

Complete 

101 

Partial 

110 

Almost  complete 

70 

Slight                   I 

110 

Blood  picture  ehortly 
before  autopey 


HiEnioglobin 


R.  B.  C. 


4,510,000 
6,050,000 
2,970,000 
5,820,000 
5,680,000 
4,530,000 
3,860,000 
4,410,000 
4,040,000 
6,120,000 
4,9'.  0,000 
4,920,000 
6,048,000 
5,100,(X)0 
.".,206.000 
4,480,000 
6,200,000 


but  of  the  cross-section.  "  Slight  streaking "  and 
"  streaked  "  refer  to  an  intermingling  of  yellow  and  red 
marrow.  A  marrow  is  described  as  "  red  "  only  when  it 
is  uniformly  so.  As  will  be  seen  by  a  c  '^.parison  of  gross 
and  microscopic  appearances,  a  man"  "  yellow  "  to  the 
naked  eye  may,  microscopically,  show  evidence  of  begin- 
ning hyperplasia.    The  early  changes  are  indicated  by  the 


148 


THE  SPLEEN  AND  ANAEMIA 


word  "  slight."  The  word  "  complete  "  indicates  that  only 
an  occasional  fat  cell  is  seen  microscopically.  "  Almost 
complete  "  means  that  fat  cells  occupy  less  than  one-tenth 
of  the  marrow  space  in  the  surface  area  of  sections  studied. 
Several  purely  fatty  marrows  representing  periods  be- 
tween five  and  twenty-four  days  after  splenectomy  are 
not  included  in  the  table. 

The  bone-marrows  representing  the  earlier  periods  of 
splenectomy,  in  that  they  show  praoti(^illy  no  changes,  may 
l)e  dismissed  briefly.  This  is  true  of  a  series  from  animals 
killed  at  various  intervals  from  five  days  to  three  months. 
Some  of  these  marrows  c^innot  be  distinguished  from  those 
of  the  normal  dog.  In  others,  slight  replacement  of  fatty 
tissue  is  seen.  Thus  one  representing  the  twenty-fourth 
day  shows  here  and  there  between  the  fat  cells  single  rows 
of  blood-forming  cells,  with  now  and  then  clumps  of  ten 
to  thirty  or  more.  These  areas  are  neither  purely  erj'thro- 
genetic  nor  purely  leucogenetic,  though  in  some  of  the 
groups  with  an  older  type  of  cells  there  is  a  predominance 
of  polynucleated  cells.  THe  endothelial  cells  of  the  reticu- 
lum not  infrequently  contain  large  masses  of  old  blood- 
pigment. 

Another,  representing  the  fortieth  day,  presents  prac- 
tically the  same  appearance,  with  a  tendency,  however,  to 
greater  erythrogcnesis.  On  the  other  Hand,  a  thirty-nine 
day  dog  shows  a  simple  fatty  marrow  with  no  evidence  of 
active  blood  formation.  Three  other  marrows  of  this 
period,  however,  show  already  the  early  stages  of  hyper- 
plasia; both  types  of  cell  groups  can  occasionally  be  iso- 
lated, but  usually  the  groups  are  mixed.  Greater  numbers 
of  eosinophile  cells,  both  myelocytic  and  polymorphonu- 
clear, are  present  than  have  been  evident  in  earlier  periods. 


CHANGES  IN  BONE-MARROW 


149 


A  number  of  cells  throughout  the  section  correspond  to 
Lon^cope's  *''^  small  lymphocytes,  and  a  smaller  number 
to  Longcope's  large  lymphwytes.  The  small  lympho- 
cytes are  not,  however,  in  pure  groups.  Polymorphonu- 
clear leucocytes  are  abundant,  and  the  picture,  as  a  whole, 
is  one  of  leucogenesis  rather  than  of  erythrogenesis.  Very 
few  giant-cells  are  seen,  and  only  occasional  phagocytes. 

In  another  m-.rrow  of  the  sixty-third  day  a  moderate 
peripheral  hyperplasia  of  mixed  type  is  present.  Marked 
congestion  is  evident  between  the  fat  cells,  and  hyper- 
plasia is  seen,  in  places,  near  the  periphefr}-;  in  some  in- 
stances the  erythrocj-tes  appear  to  be  outside  the  vessel, 
forming  distinct  areas  of  hemorrhage.  A  few  phagocytes 
are  present,  but  giant-cells  are  rare.  Polymorphonuclears 
are  fre(iuent  and  of  mature  development.  At  the  periphery 
erythrogenesis  seems  to  predominate  over  leucogenesis. 
Eosinophiles  and  lymphoid  cells  are  not  conspicuous. 

A  marrow  of  tlie  sixtieth  day  shows  less  hyperplasia, 
but  leucocytie  reaction  is  more  evident,  though  erj-thro 
gjmesis  is  active.     Scattered  throughout  tlie  section  are 
many  small  lymphocytes,  but  nowhere  are  these  seen  in 
solid  clumps.     Numerous  deposits  of  pigment  are  seen. 

Again,  on  the  eighty-fourth  day,  an  essentially  fatty 
marrow  shoMs  a  narrow  cellular  strip  at  the  periphery  in 
which  erythrogenesis  is  quite  active.  Here  an<i  there 
leucogenesis  predominates,  but  in  the  main  the  process  is 
erythrogenetic,  A  few  nucleated  red  cells  of  the  megalo- 
blastic type  are  four  ^  l)ut  the  more  mature  normoblasts 
are  more  abundant.  In  some  centres  radiating  lines  of 
four  or  five  normoblasts  are  seen.  Few  giant-cells  are 
present. 

The  manows  of  the  fourth  and  fifth  months  after 


*8 

I » 


150 


THE  SPLEEN  AND  ANiKMIA 


splenectomy  are  not  represented  in  this  study.     Well- 
marked  hyperplasia  is,  however,  present  in  bone-marrow 
representing   periods   of   six,    seven,    twelve,   seventeen, 
eighteen,  and  twenty  months  after  splenectomy.    On  the 
other  hand,  two  marrows  representing  respectively  nine  and 
one-half  and  ten  months  show  no  departure  from  the  nor- 
mal fatty  marrow,  and  in  a  third   (eighth  month)   only 
slight  hyperplasia  is  evident.    In  the  latter  are  areas  com- 
posed almost  entirely  of  cells  of  the  myelocyte  or  pre- 
myelocyte  type,  with  some  evidence  of  the  formation  of 
both  red  cells  and  polymorphonuclear  leucocy-tes.     The 
picture  suggests  a  proliferation  of  the  primitive  cells  of 
the  marrow,  without,  however,  a  very  active  further  differ- 
entiation.   In  a  fourth  animal  of  the  late  period  (twenty- 
second  month)  only  slight  hyperplasia  was  present.    With 
evidence  of  well-marked  hyperplasia  in  other  animals  at 
six  and  seven  months  after  splenectomy  and  after  a  year 
and  a  half,  it  is  impossible  to  explain  its  failure  in  these 
four  animals  representing  the  eighth,  nintli,  tenth,  and 
twenty-second  months  respectively. 

The  best  opportunity  of  studying  the  late  changes  is 
presented  by  material  from  six  animals,  representing  the 
period  from  six  to  twenty  months,  in  all  of  which  the 
fatty  marrow  of  the  femur  was  transformed  entirely  or 
iri  large  part  into  red  marrow.  The  histological  picture  of 
each  of  these  will  be  given  in  detail. 

Dog  /o.— Splenec^r.nized  May  20,  1913.  Before  oper- 
ation tiie  red  cells  numbered  0,910.000  and  the  hsemoglobin 
was  105  per  cent.  The  severest  anaemia  was  reached  July 
21:  red  cells  4,240,000,  h{pmoglo')in  62.  On  September 
11th  the  figures  were  .5,220,000  and  02.  I^ater  the  animal 
became  pregnant  and  anemia  recurred,  the  picture  on  No- 


CHANGES  IN  BONE-MARROW 


151 


vember  18  being  red  cells  4,410,000,  hemoglobin  78  per 
cent.  On  November  24  the  animal  was  chloroformed.  At 
autopsy  the  medulla  of  both  femurs  presented  a  deep-red 
marrow. 

Histologically  is  seen  a  uniformly  cellular  tissue,  with 
only  occasionally  a  fat  space  here  and  there  at  the  pe- 
riphery. For  the  most  part  this  marrow  is  as  definitely 
cellular  as  is,  for  example,  a  lymph-node  or  the  spleen,  and 
indeed,  it  has  much  of  the  appearance  of  the  pulp  of  the 
latter  organ  in  the  new-born  puppy.  In  this  cellular  mass, 
which  at  first  appears  to  present  a  hopeless  confusion  of 
cells,  it  is  not  difl5cult  to  resolve  the  cells  into  more  or  less 
distinct  proliferating  centres.  The  arrangement  is  by  no 
means  a  definite  one,  but  in  the  patchwork  of  cells  one 
sees  groups  which  correspond  to  Bunting's  description.  In 
speaking  of  these  centres  we  will  refer  to  them  as  erythro- 
genetic  or  leucogenetic,  according  to  whether  red  cells  or 
polymorphonuclear  leucocytes  predominate  in  the  mass  of 
cells  surrounding  the  centre  in  question.  We  have  made 
no  attempt  to  distinguish  in  these  centres,  which  may  in- 
clude from  six  to  thirty  cells,  between  the  finely  granular 
neutrophilic  myelocyte  and  the  non-granular  basophilic 
cell  from  which  it  is  supposed  to  arise.  In  these  centres 
mitotic  figures  may  occasionally  be  seen,  but  only  after 
prolonged  search.  It  is  also  in  these  centres  that  old 
blood-pigment,  which  is  quite  abundant  in  this  marrow, 
is  deposited;  its  deposition  in  the  loose  vascular  tissue 
elsewhere  has  not  been  obsen^d.  The  erythrogenetic 
centres  appear  to  be  more  active  than  the  leucogenetic. 
This  impression  is  based  on  the  fact  that  about  a  mass  of 
myeloblasts,  composed  of  twelve  to  fifteen  cells,  may  be 
seen  twenty-five  to  thirty  nucleated  red  cells  and  a  small 


rli 


\5i 


TOE  SPLEEN  AND  ANEMIA 


number  of  normocytes,  while  about  the  leucogenetic  centres 
comparatively  few  leucocytes  are  seen.  The  red  cells  in 
question  van,'  in  size  and  show  intermediate  stages  from 
the  megaloblast  to  the  normocyte.  It  is  not  to  be  supposed 
that  about  erythrogenetic  centres  no  leucocytes  occur;  a 
few  are  always  present.  For  example,  among  the  twenty- 
five  to  thirty  cells  mentioned  above,  eight  polymorphonu- 
clear leucocytes  could  be  clearly  distinguished.  Sometimes 
on  one  side  of  a  centre  nucleated  erythrocytes  may  be 
grouped,  and  on  the  other  leucocytes,  with  little  inter- 
mingling. This  suggests  simnltaneous  formation  of  the 
two  cells  in  one  cell  centre.  Wiien  this  occurs  the  number 
of  red  cells  is  always  greater  than  the  number  of  leuco- 
cytes, in  proportion  of  about  4  to  1.  All  through  the 
section  are  lymphoid  cells,  usually  single  and  of  the  small 
variety.  Giant-cells  are  frequent,  and  a  few  show  inclu- 
sions of  polymorplionuclear  leucocytes.  Cells  containing 
such  inclusions  have  a  broad,  homogeneous  gray  staining 
protoplasm  suggesting  necrosis.  Th?re  is  considerable 
pigment,  but  not  many  phagocytic  endothelial  cells  are 
seen.  Normoblasts  are  seen  free  in  the  capillaries.  Smears 
from  the  marrow  of  the  ribs  show  active  erythrogenesis 
and,  on  the  whole,  much  the  same  cellular  picture  as  the 
marrow  just  described.  In  the  rib-marrow  a  considerable 
nimiber  of  eosinophiles,  chiefly  polymorphonuclears,  are 
also  seen.  In  con  'taction  with  the  activity  in  the  formation 
of  red  cells  shown  by  the  marrow,  it  is  significant  that  tlie 
blood  count  six  days  before  death  was  4,100,000  and  the 
h.Tmoglobin  78  per  cent,  (on  September  n,  four  months 
after  splenectomy,  the  figures  were  .5,240,000  and  92). 
In  other  words,  despite  the  hyperplasia  of  the  bone-mar- 
row, the  animal  exhibited  a  late  ana?mia,  two  and  a  half 


CHANGES  IN  BONE-MARROW 


US 


months  after  recovery  from  the  initial  anemia,  following 
splenectomy.  This  niay  have  been  due  to  the  drain  occa- 
sioned by  the  intervening  pregnancy— an  unfortunate 
complication  from  the  point  of  view  of  the  study  of  the 
hl{M>d.  The  fact  remains,  however,  that  the  marrow  is 
actively  forming  normal  red  cells.  The  anemia  was,  there- 
fore, not  due  to  abnormally  low  erj'tlu-ogenesis  in  thr 
marrow. 

Dog  SO.— On  April  7,  1913,  before  splenectomv,  the 
red  cells  numbered  6,528,000,  and  hjemoglobin  was  110 
per  cent.  The  lowest  point  of  ana?mia  was  reached  on 
June  3,  the  red  cells  numbering  at  that  time  3,6.50,000;  the 
ha'moglobin  was  62  per  cent.  By  July  7  the  blood  picture 
had  improved  (red  cells  5,080,000,  ha?moglobin  88  per 
cent.),  but  on  September  11  a  late  recrudescence  of  the 
ancTmia  gave  red  cells  4,040,000  and  hfemoglobin  68  per 
cent.  The  animal  was  killed  on  Xovember  15.  The  bone- 
marrow  of  the  femur  was  of  a  definite  red  color.  The 
ana?mia  did  not  affect  the  general  nutrition  of  the  animal, 
for  on  April  7  the  weight  was  12,800  gms.;  on  November 
15  it  was  13,950,  and  the  adipose  tissue  was  abundant. 

This  animal,  representing  practically  the  same  period 
after  splenectomy  and  the  same  clianges  in  the  blood  as 
Dog  10,  gives  very  much  the  same  picture  in  the  marrow. 
Of  minor  importance  is  the  fact  that  the  marrow  is  nol 
so  cellular,  the  proportion  of  cells  to  fat  being  in  the  ratio 
of  about  3  to  2;  also,  the  myelocytic  centres  are  not  so 
pronounced,  but  in  other  respects  the  marrow  is  the  same. 
Many  giant-cells  are  present,  but  lymphoid  cells  are  rare. 
The  formation  of  red  cells  and  leucocj'tes  is  perhaps  not 
so  rapid  (that  is,  the  numbers  about  any  one  centre  are  not 
so  great),   bnt,  on   the  other  hand,   the  erj-throgenetic 


IN 


M 


154 


THE  SPLEEN  AND  ANAEMIA 


activity  of  the  marrow  is  sufficient  to  exclude  the  possi- 
bility of  an  inactive  bone-marrow  being  responsible  for  the 
late  recrudescence  of  anaemia. 

Docf  24. — This  animal  was  splenectomized  on  Febru- 
ary 10,  1912,  and  was  used  for  the  injection  of  haemolytic 
immune  serum  on  March  20  and  again  on  April  7.  On 
June  28  it  had  recovered  from  the  anaemia  then  produced 
(red  cells  5,650,000,  haemoglobin  89  per  cent.),  and  on 
July  15  it  was  treated  with  sodium  oleate.  On  Septem- 
ber 26  the  red-cell  count  was  5,780,000  and  haemoglobin 
90  per  cent.  On  February-  19,  1913,  the  blood  picture 
had  improved  (red  cells  6,048,000,  haemoglobin  110  per 
cent. ) ,  and  at  this  time  hemolytic  serum  was  again  injected. 
The  animal  was  chloroformed  on  March  4, 1913.  The  lapse 
of  time  since  splenectomy  was,  therefore,  thirteen  months. 
At  autopsy  a  red  marrow  was  found. 

Owing  to  the  use  of  various  hemolytic  poisons,  the 
bone-marrow  of  this  animal  may  have  been  influenced  by 
other  factors  than  the  absence  of  the  spleen.  The  his- 
tological picture,  however,  is  so  in  accord  with  the  marrow 
of  simple  splenectomy  that,  with  this  explanation,  it  is 
included  in  the  series. 

Histology. — The  marrow  is  a  uniformly  solid  marrow, 
with  no  fat  spaces  visible  in  any  of  the  sections  examined. 
It  does  not,  however,  appear  to  be  as  cellular  as  the  marrow 
of  Dogs  10  and  39.  This  difference  is  caused  by  a  greater 
congestion  and  distention  of  the  blood-vessels,  a  slight  in- 
crease in  the  reticiil  iiri,  and  a  lessened  tendency  of  the 
myelocytic  tissue  to  be  grouped  in  large  centres.  Ery- 
throblastic centres  are  very  prominent  and  very  active; 
leucogenetic  centres,  on  the  other  hand,  are  made  out  with 
i'iRculty.    L>Tnphoid  elements  are  rare.     Many  cells  of 


■^^t^m.r/'''  T'^m^^m^  ^- ' -^^f^^^^^  :^m 


CHANGES  IN  BONE-MARROW 


155 


the  myelocytic  type  are  seen  with  coarse  basic  granules 
and  short  threads  in  the  nucleus  and  with  little  or  no 
protoplasm.  In  close  relation  to  these  are  sometimes  seen 
degenerated  mitotic  cells,  but  whether  all  the  chromatin 
masses  can  be  so  interpreted  is  not  clear.  These  degenera- 
tive changes  are  doubtless  the  result  of  the  last  injection  of 
haemolytic  serum. 

Dog  59.— On  July  24,  1912,  this  animal  was  splenec- 
tortized  and  used  for  the  study  of  the  progressive  anaemia 
following  this  procedure.     On  December   7,    1912,   the 
highest  point   (red  cells  5,250,000,  hemoglobin  105  per 
cent.)  of  recovery  was  reached.     Continued  observation 
showed  a  slight  decline  to  5,2)00,000  red  cells  and  86  per 
cent,  of  hajmoglobin  on  May  21,  1913,  on  which  date  the 
animal  was  used  in  an  experiment  with  sodium  oleate. 
From  the  moderate  ansemia  caused  at  this  time  the  animal 
recovered,  the  blood  examination  on  June  9  showing  5,050,- 
000  red  cells  and  86  per  cent,  haemoglobin,  the  condition 
slightly  improving  as  to  ha?moglobin  content  until  Novem- 
ber 18, 1918,  when  red  cells  were  5,100,000  and  hsemoglobin 
101  per  cent.    The  animal  was  chloroformed  on  Novem- 
ber 24.    At  autopsy  the  bone-marrow  of  the  femur  was 
soft,  succulent,  and  dark  red  in  color.    In  connection  with 
the  general  condition  of  this  animal  it  is  of  interest  to 
note  that  in  the  last  seven  months  its  weight  increased 
from  10,450  grammes  to  12,580  grammes,  and  that  adipose 
tissue  was  verj'  abundant.    The  administration  of  sodium 
oleate  introduces  a  possible  disturbing  factor,  but  ns  this 
was  given  six  months  before  death,  and  as  the  anemia 
which  it  caused  was  quickly  repaired,  it  is  not  considered, 
in  view  of  our  other  observations,  to  have  had  an  important 
influence  on  the  bone-marrow. 


t^-tf-Vi*'  -fi^^HT^^-'-r 


156 


THE  SPLEEN  AND  AN.EMLV 


iss:^: 


HisToi-(X?v. — The  marrow  shows  some  fat  cells,  the 
proportion  of  marrow  cells  to  fat  being  about  10  to  1. 
Nothing  different  from  the  last  four  marrows  is  pre- 
sented. Leucogentsis  and  er>-throgenesis  proceed  at  about 
equal  rate,  the  latter  being  a  little  more  active.  ^Mitotic 
figures  are  seen  not  infrequently,  but  the  type  of  cell  in 
which  they  occur  is  not  always  evident.  Myeloblasts  seem 
to  be  more  abundant  than  usual.  Giant-cells  are  fairly 
abundant,  but  lymphoid  cells  are  rare. 

Doc/  ,77._On  June  23,  1912,  the  blood  of  this  dog  con- 
tained 5,350,000  red  cells  per  cubic  millimetre  and  98  per 
cent,  hipmoglobin.  On  July  2  the  spleen  was  removed. 
The  resulting  ana?mia  reached  its  lowest  point  (red  cells 
2,970,000,  haemoglobin  50  per  cent.),  on  August  5.  On 
October  24,  when  the  bl«)od  count  showed  5,240,000  red 
cells  and  90  per  cent,  haemoglobin,  the  animal  received 
sodium  oleate  intravenously ;  a  slight  amemia  ( fall  in  hsEmo- 
globin  to  62  per  cent.,  but  no  marked  change  in  red  cells) 
resulted.  In  Januan-,  1913,  the  red  cells  were  5,206,000, 
hsemoglobin  110  per  cent.,  and  with  slight  variations  this 
higher  level  was  maintained,  accompanied  by  an  increase 
in  body  weight,  until  December  12,  1913,  when  the  animal 
was  chloroformed.  At  autopsy  the  animal  was  found  to 
have  a  large  amount  of  adipose  tissue;  the  bone-marrow  of 
the  femur  was  definitely  reddish  in  color,  with  faint  yellow- 
ish streaks.  As  the  sodium  oleate  given  four  months  after 
splenectomy  and  fourteen  months  before  death  produced 
only  a  slight  transient  change,  we  consider  that  the  bone- 
marrow  represents  the  effect  of  splenectomy  only. 

Histological  Examination. — The  relation  of  the  fat 
to  cells  is  about  1  to  1 ;  otherwise  nothing  new  is  seen.  The 
marrow  is  very  active,  leucogenesis  and  erythrogenesis 


CHANGES  IN  BONE-MARROW  157 

being  equally  prominent.  Phagocytic  cells  and  masses  of 
old  olood-pignient  are  quite  numerous,  as  are  also  giant- 
cells.  More  abundant  than  in  other  marrows  are  eosino- 
philes  of  the  myelocytic  type.  Lymphoid  cells  are  not 
conspicuous. 

Dog  ,«.— This  animal  was  splenectomized  on  May  14, 
1012.  The  blood  examination  on  the  previous  day  showed 
4,950,000  red  cells  and  85  per  cent,  hicmoglobin.  The 
anicmia  following  splenectomy  reached  its  lowest  point  on 
June  28  (red  cells  3,550,000,  haMiioglobin  52  per  cent.). 
On  September  20  the  red  cells  had  risen  to  5,490,000  and 
hicmoglobin  to  95  per  cent.  In  November,  1913,  the 
animal  passed  successfully  through  pregnancy.  In  Janu- 
ary-, 1914,  as  the  animal  had  developed  mange,  it  was 
chloroformed.  The  blood  examination  on  the  preceding 
(lay  was  red  cells  4,480,000,  hemoglobin  70  per  cent.  At 
autopsy  the  bone-marrow  of  the  femur  was  deep  red  in 
color.  (It  should  he  stated  that  one  and  two  months 
before  splenectomy  the  animal  had  received  injections  of 
hfcmolytic  serum.  From  our  studies  of  the  effect  of  hemo- 
lytic serum  in  the  normal  dog,  we  do  not  believe  that  these 
injections,  several  weeks  before  splenectomy  and  nearly 
two  years  before  death,  are  in  any  way  responsible  for 
the  hyperplasia  of  the  marrow.) 

Histological  Examixatiox.— This  marrow  differs  in 
no  way  from  the  marrows  of  Dogs  57  and  59  described 
above. 

Dog  51. — The  spleen  was  removed  on  May  31,  1912, 
and  on  June  26  of  the  same  year  hemolytic  serum  was 
administered.  From  the  anemia  thus  produced  the  animal 
made  a  slow  recovery,  but  after  200  davs  the  blood  examin- 
ation showed  6,200,000  red  cells  and  110  per  cent,  hemo- 


I' 


f  1 


^T«*^i- w*i>^^-»^  .  -f 


U8 


THE  SPLEEN  AND  AN.EMIA 


globin,  as  compared  with  (5,210,000  red  cells  and  100  per 
cent,  ha'nio^lohin  before  splenectomy.  On  March  26,  1014, 
when  the  animal  was  chloroformed,  its  weight  was  0750 
^ammes,  as  compared  with  8270  grammes  at  the  time  of 
splenectomy  and  8120  grammes  when  hemolytic  serum 
was  administered.  The  notes  made  at  the  autopsy  refer 
to  the  large  amount  of  adipose  tissue,  the  normal  appear- 
ance of  the  lymph-nodes,  the  absence  of  superimmerary 
spleens,  and  the  presence  in  the  long  bones  of  a  distinctly 
yellow,  fatty  marrow.  Histological  examination  of  the 
marrow  shows  a  very  slight  hyperplasia,  with  large  num- 
bers of  leucocytes  and  deposits  of  blood-pigment. 

Discussion. — It  will  be  remembered  that  in  discussing 
the  anjemia  which  follows  splenectomy  it  was  pointed  out 
that  nucleated  and  other  abnormal  forms  of  red  cells  are 
rarely  found  in  the  circulating  blood,  and  that  when  they 
do  occur  they  do  not  persist  for  any  length  of  time.  Appar- 
ently their  appearance  corresponds  to  the  beginning  repair 
and  not  to  the  period  of  hyperplasia  of  the  marrow  which 
we  have  described.  It  is  difficult,  therefore,  to  bring  the 
changes  in  the  bone-marrow  into  relation  with  the  changes 
in  the  peripheral  blood.  If  the  hyperplasia  of  the  bone- 
marrow  is  compensatory  to  increased  blood  destruction  or 
decreased  blood  formation,  one  would  expect  definite 
hyperplasia  to  be  present  in  the  earlier  period,  during  the 
first  three  months  after  splenectomy,  at  a  time  when  the 
anaemia  is  evident  and  repair  is  taking  place,  and  not  after 
six  months  to  a  year  or  a  year  and  a  half,  when  the  blood 
picture  Is  normal.  It  is  true  that  in  two  of  the  animals 
(Dogs  10  and  39)  a  late  recrudescence  of  anaemia  occurred 
and  the  marrows  of  these  animals  were  obtained  during 
this  period,  but  this  was  not  the  case  in  most  of  the  animals 


C  HANGES  IN  BUNE-MAHROW  iffO 

of  the  series  and  is  not  characteristic  of  the  late  periods 
after  splenectomy.  It  is  therefore  impossible,  on  account 
of  the  late  development  of  hyperplasia  in  the  man-ow.  to 
explain  its  occurrence  as  compensatorv  ,  >  the  anemia  fol- 
lowing splenectomy. 

Likewise  we  cannot  accept  W^arthin's  '«•  theory  based 
upon  his  study  of  sheep  and  goats.  In  these  animals 
Warthm  found  hyperplasia  of  the  marrow  to  occur  several 
months  after  splenectomy  and  to  be  associated  \  "h  evi- 
dence of  increased  destruction  of  red  blood-cells  in  the 
lymph-  and  hsmolymph-nodes.  This  destruction,  greater 
than  that  in  the  primitive  spleen,  is  responsible,  he  be- 
lieves, for  the  anajmia  following  splenectomy,  and  this  is 
in  turn  compensated  by  increased  activity 'in  the  bone- 
marrow.  We  have  found  little  to  support  this  theory  in 
our  studies  of  the  dog.  The  lymph-nodes,  as  well  as  the 
endothelial  cells  of  the  liver,  as  we  have  shown  elsewhere,'' ^=' 
are  indeed  more  active  in  the  phagocytosis  and  destruction 
of  red  cells  after  splenectomy  than  in  the  normal  animal, 
and  this  is  very  evident  when  large  numbers  of  red  cells 
are  injured,  as  by  the  administration  of  a  hemolytic  poi- 
son ;  but  in  the  ordinary  course  of  events,  after  splenectomy, 
the  IjTnph-nodes  present  no  evidence  of  excessive  blood 
destniction.  An  occasional  cell  containing  one  or  two  red 
cells  may  be  seen,  and  small  amounts  of  old  blood-pigment 
are  occasionally  demonstrable,  but  of  excessive  hemolysis 
there  is  no  evidence.  Likewise,  microchemical  tests  'for 
iron  m  the  lymph-nodes  and  liver  show  that  little  differ- 
ence exists  in  this  respect  between  the  normal  and  splenec- 
tomized  animals.  For  this  reason,  and  because  the  anaemia 
is  not  persistent  and  progressive,  we  cannot  support  the 
theory  that  the  hyperplasia  of  the  marrow  is  compen- 


£l 


tf^ 


'I 


ti 


»ii 


160 


THE  SPLEEN  AND  ANEMIA 


satory  to  abnormal  blood  destruction  in  the  Ijinph-nodes. 

Another  possible  explanation  is  that  the  bont  marrow, 
in  the  absence  of  the  spleen,  is  concerned  in  the  storing 
and  utilization  of  iron.  There  is  no  v^oubt  that,  in  the 
normal  animal,  iron  set  free  in  the  dissolution  of  red  cells 
is  stored  in  the  spleen.  After  splenectomy  a  readjust- 
ment in  the  storage  of  iron  takes  place,  and  there  is  some 
evidence  that  for  a  short  time  after  the  removal  of  the 
spleen  iron  may  be  lost  from  the  body.  Our  investiga- 
tions ""  show,  however,  that  this  disturbance  of  iron  utiliza- 
tion is  transient,  and  that  after  a  few  weeks  the  elimina- 
tion of  iron  in  the  splenectomized  animal  differs  in  no  way 
from  the  process  in  the  normal  animal.  This  suggests 
naturally  that  the  storage  of  iron  in  the  absence  of  the 
spleen  is  taken  over  by  other  tissues.  As  microchemical 
tests  for  iron  showed  no  definite  increase  of  iron  in  the 
lymph-nodL's  and  liver,  it  seemed  probable  that  the  bon.' 
marrow  might  l)e  the  chief  depot  of  iron  storage.  Sucii 
a  view  was  supported  by  the  fact  that  all  hyperplastic 
bone-marrows  contain  large  amounts  of  altered  blood- 
pigment,  sometimes  free,  but  (w^curring,  for  the  most  part, 
in  large  phagocytic  cells.  The  activity  of  these  phagocytic 
cells  in  transforming  the  iron  of  old  blood-pigment  in  order 
that  it  may  be  utilized  ff)r  red  cells  might,  it  was  plausible 
to  suppose,  stinuilate  the  other  functions  of  the  bone- 
marrow  (that  is,  the  erythrogenetic  and  leucogenetic  func- 
tions) and  cause  eventually  a  replacement  of  the  fatty 
marrow  by  a  ver\'  oellular  red  marrow. 

In  order  to  prove  this  hypothesis  it  was  necessary  to 
obtain  some  idea  of  the  iron  content  of  these  marrows. 
Direct  chemical  analysis  was  nut  of  the  question  on  account 
of  the  small  amoimt  of  material  available  and  the  varia- 


ir^-'r-^:'^'Y\W^ 


CHANGES  IN  BONE-xMARROW  Ml 

tions  in  blood  and  bone  content  of  different  marrows.  We 
therefore  made  a  comparative  study  based  on  the  use  of 
the  microchemical  reaction  for  iron.     This  demonstrated 
at  once  that  all  red  marrows  in  our  series  have  a  large  con- 
tcJil  of  iron,  and  that  fatty  marrows  contain  very  little 
()-•  no  iron.    On  the  other  hand,  when  the  marrows  of  non- 
splenectomized  dogs  rendered  hyperplastic  by  anaemia  or 
infection  were  examined  it  was  found  that  these  also  had 
a  large  iron  content.    Thus  in  a  group  of  seventeen  non- 
splenectomized  dogs  iron  was  present  in  the  marrow  in 
large  amounts  in  four,  in  moderate  amounts  in  two,  in 
siiiall  amounts  in  four,  and  in  seven  none  was  found.    On 
the  other  hand,  in  twenty-seven  splenectomized  dogs,  iron 
was  present  in  large  amounts  in  ten,  in  modei  .te  amounts 
111  three,  small  amounts  in  four,  and  absent  in  ten. 

In  both  groups  the  amount  of  iron  was  in  direct  pro- 
portion to  the  degree  of  hyperplasia.    These  observations 
pomt,  therefore,  to  the  conclusion  that  a  red  marrow  is 
always  rich  in  iron,  but  it  is  impossible  to  say  whether  the 
cellular  hyperplasia  or  the  iron  deposition  is  primary. 
Tnder  the  circumstances,  it  is  also  impossible  to  conclude 
that  the  late  hyperplasia  of  marrow  following  splenectomy 
IS  an  attempt  to  conserve  iron.    Moreover,  the  irregularity 
of  our  results,  as  shown  by  the  failure  of  hyperplasia  in 
four  animals,  representing  respectively  the  eighth,  ninth, 
tenth,  and  twenty-second  months  after  splenectomy,  pre- 
vents, in  the  present  state  of  our  knowledge,  an  adequate 
explanation  of  the  cause  of  the  transformation  from  yellow 
to  red  marrow.    However,  the  tardiness  with  which  hyper- 
plasia of  the  bone-marrow  appears  after  splenectomy,  de- 
spite the  presence  of  an  aiia?mia  of  considerable  grade,  may 
well  bear  some  causative  relation  to  the  slow  degree  of 
11 


I 


I6i 


THii  SPLEEN  A%D  ANJIMIA 


i?.. 


blood  regeneration  that  follows  the  administration  of 
hsemolytic  agents  to  such  animals. 

The  divergent  results  in  this  study  are  characteristic 
of  all  phases  of  experimental  work  on  the  spleen,  and 
doubtless  are  to  be  explained  by  the  fact  that  removing 
the  spleen  takes  away  only  one  organ  of  a  system  com- 
posed of  liver,  spleen,  lymph-nodes,  and  bone-marrow,  and 
that  the  interrelations  which  exist  in  this  system  may,  or 
may  not,  under  varying  circumstances,  bring  into  play 
compensations  of  the  greatest  importance  in  determining 
the  degree  of  blood  destruction  or  regeneration  and  there- 
fore the  degree  of  change  in  the  bone-marrow. 

A  search  of  the  literature  of  splenectomy  in  man, 
although  it  reveals  evidence  of  the  occurrence  of  red  mar- 
row in  various  forms  of  splenic  ana?mia,  offers  little  of  im- 
portance concerning  the  changes  which  occur  in  the  bone- 
marrow  after  i  moval  of  the  normal  spleen.  Several  refer- 
ences are  made  to  the  occurrence  of  pain  in  the  long  bones 
after  splenectomy,  and  by  some  this  has  been  assumed  to 
be  evidence  of  hyperplasia  within  the  rigid  bony  canal. 
The  only  note  of  the  direct  examination  of  the  bone-marrow 
after  splenectomy  is  that  of  Riegner,"'"  who  found  active 
proliferation  of  the  marrow  of  the  femur  in  a  man  whose 
leg  was  amputated  for  gangrene  four  weeks  after  splenC'V 
tomy  for  trauma.  It  is  therefore  impossible,  on  account 
of  this  paucity  of  data  concerning  the  changes  in  man,  to 
bring  them  into  relation  with  our  experimental  results. 

Conclusions. — Splenectomy  in  the  dog  causes,  as  a 
rule,  a  transformation  of  the  fatty  marrow  of  the  long 
bones  into  a  richly  cellular  red  marrow. 

During  the  early  periods,  one  to  three  months,  the 
change  in  the  marrow  is  slight  and  either  focal  or  pe- 


CHANGES  IN  BONE-AL*  RROW  les 

ripheral;  after  six  to  twenty  months  the  replacement  of 
fat  by  marrow  cells  is  complete  or  nearly  so.  Excep- 
tions were,  however,  seen  in  four  animals  representing 
the  eighth,  ninth,  tenth,  and  twenty-second  months 
respectively. 

The  evidence  at  hand  does  not  support  the  theory  that 
this  hyperplasia  is  compensatory  either  to  *he  anemia 
caused  by  splenectomy  or  to  an  increased  hemolysis  in  the 
lymph-nodes.  li  is  possible  that  it  may  be  a  concomitant 
of  the  activity  a  the  bone-marrow  in  taking  over,  in  the 
absence  of  the  spleen,  the  function  of  storing  and  elaborat- 
ing the  iron  of  old  blood-pigment  for  future  utilization  by 
new  red  cells,  but  our  studies  do  not  fully  support  this 
view. 


>'! 


P 


m 


Hi 


■..']: 


CHAPTER  VII 

THE  CHANGES  IN  THE  LIVER  \SD  LYMPH-NODES  AFTER 

SPLENECTOMY 

DISCUSSION  OF  THE  LITERATURE.  CHANGES  IN 
LYMPH-NODES.  PHAGOCYTOSIS  OF  RED  CELLS 
BY  ENDOTHELIAL  CELLS  OF  LYMPH-NODES 
AND  LIVER.  MICROCHEMICAL  TEST  FOR  IRON 
IN   LYMPH-NODES   AND   LIVER. 

Much  of  the  early  literature  concerning  compensatory 
changes  in  the  lymph-nodes  is  bound  up  with  the  question 
of  the  regeneration  of  the  spleen  after  partial  or  complete 
extirpation  and  more  recently  witli  problems  concerning 
the  htemolymph-nodes.  As  this  literature  has  been  col- 
lected very  completely  by  Warthin,^"'  we  will  give  only  a 
general  simmiary  of  it  in  the  li'jfht  of  his  investigation.  The 
earliest  detailed  investigations  are  those  of  Tizzoni  and 
Fileti,*'"  who  observed  in  the  splenectomized  dog  an  in- 
crease in  size  of  the  retroperitoneal  and  thoracic  lymph- 
nodes,  which  were  distinctly  red  in  color.  In  two  dogs, 
splenectomized  for  fifty-four  days  and  three  and  a  half 
monllis  respectively,  they  found  a  new  formation  of  spleen- 
like nodules  in  tlie  onirntum.  These  they  believed  to  be 
formed  directly  from  adipose  tissue  by  an  absorption  of 
fat  and  a  transformation  of  the  fat  cells  into  reticulum. 
I.,eucocytic  infiltration  followed,  as  also  proliferation  of 
endotlielium,  which  produced  eventually  a  pulp-like  tissue, 
in  the  meslies  of  which  were  red  blood-cells.  Around  the 
whole  a  coimcctive-tissue  capsule  was  formed.  Later,  in 
164 


CHANGES  IN  LIVER  AND  LYMPH-NODES  165 

1882,  Tizzoni^^**   found  somewhat  similar  bodies  in  the 
gastr'osplenic  ligament,  in  connection  with  indurative  sple- 
nitis in  the  dog,  and  after  splenectomy  numerous  newly- 
formed  nodules  throughout  the  subperitoneal  fat,  over  the 
diaphragm,  and  in  the  pelvic,  sterno-abdominal  and  sub- 
cutaneous fat  tissue.     Fca,""  in  1883,  denied  the  new 
formation  of  such  n(  des,  and  explained  them  as  preexist- 
ing nodes,  changed  in  color  by  hemorrhage  or  other  patho- 
logical  conditions.     In  the  meantime,  however,  Wino- 
gradow'"  had  described  in  dogs  killed  132,  517,  and  760 
days  after  splenectomy  changes  in  existing  lymph-nodes 
similar  to  those  observed  by  Tizzoni.    On  account  of  the 
presence  of  red  cells  and  pigmented  cells  in  the  sinuses  of 
these  nodes,  he  believed  these  structures  to  have  a  share 
in  blood  destruction,  and  that  possibly  the  anaemia  occur- 
ring after  splenectomy  could  in  this  way  be  explained. 

Zezas  "'  found  that  after  splenectomy  the  mesenteric 
and  bronchial  lymph-node  of  the  rabbit  became  swollen, 
(lark  red  in  color,  and  firmer  in  consistency,  and  quotes 
Hegar  and  Simon  as  finding  similar  changes  in  the  mesen- 
teric lymph-nodes  of  the  cat.    Tizzoni "«  and  Ceresole  *"» 
cov'ld  not  confirm  these  changes  in  the  rabbit.    Mosle-  ^^ 
found  in  a  dog,  splenectomized  ten  months,  numerous 
spleen-like  nodules  of  the  size  of  a  pea,  scattered  through- 
out the  greater  and  lesser  omentum.      Microscopically, 
these  were  similar  in  structure  to  those  found  by  Tizzoni 
and  Winogradow,   but  Hosier  regarded   them   as  neo- 
plasms— hemorrhagic  telangiectatic  lynphoma— and  not 
as  newly-formed  spleen  or  l>Tnph-nodes.    The  Ij-mph-nodes 
generally  were  not  hyperplastic,  and  the  bodies  described 
above  were  not  constantly  present;  in  one  dog,  for  ex- 
ample, killed  after  eleven  months,  no  changes  in  the  lym- 


166 


THE  SPLEEN  AND  AN/EMIA 


phoid  tissue  were  found.  Mosler  concludes,  nevertheless, 
that  after  splenectomy  compensatory  chanp^es  may  occur 
in  lymph-glands  and  bone-marrow. 

Gibson "°  found  in  splenectoniized  dogs  enlarged 
mesenteric  lymph-nodes  containing  both  normoblasts  and 
normocj'tes  in  their  sinuses.  Of  other  investigators,  Eter- 
nod  '*'^,  found  in  a  fox,  161  days  after  splenectomy,  a 
splenic  nodule  in  the  omentum  and  newly-formed  lymph- 
nodes  in  the  mesentery,  the  other  lymph-nodes  being  en- 
larged and  of  a  brownish  color;  Vulpius*^"  found  no 
enlargement  of  lymph-nodes  in  dogs  dying  after  a  few 
days,  or  killed  five  months  after  splenectomy;  Lauden- 
bach  ""  found  that  hyperplasia  of  the  lymph- nodes  was 
not  constant,  and  that  evidence  of  increased  blood  forma- 
tion was  present  in  the  bone-marrow  only. 

An  examination  of  Warthin's  summary  of  the  litera- 
ture concerning  the  lymph-nodes  of  man  after  splenectomy 
shows  that  no  c  ""nstant  changes  have  been  observed.  Tem- 
porary local  enlargement  of  lymphoid  tissue  has  been  ob- 
served and  occasionally  general  enlargement;  on  the 
other  hand,  in  many  cases  no  changes  whatever  have  been 
seen. 

In  the  congenital  absence  of  the  spleen,  as  in  the  case  re- 
ported by  Hodenpyl,'®*  general  enlargement  of  all  the 
lymph-nodes  of  the  body  is  found,  as  also  usually  a  new 
formation  of  lymphoid  tissue  in  the  adrenals  and  liver. 

Warthin's  studies  *^^  were  upon  sheep  and  goats  which 
normally  have  nimierous  hiemclymph-nodes  in  the  pre- 
vertebral fat.  One  and  two  weeks  after  splenectomy, 
lymph-  and  ha?mol\Tnph-glands  presented  evidence  of  an 
increased  nimiber  of  pigment-bearing  phagocytes  and 
eosinophils  and  a  proliferation  of  Ivmy^hoid  tissue  gen- 


CHANGES  IN  LIVER  AND  LYMPH-NODES 


167 


erally.  At  the  end  of  two  months  these  changes  were  more 
marked  and,  in  addition,  new  formation  of  haemolymph- 
nodes  in  adipose  tissue  was  evident.  The  changes  were 
progressive,  and  at  the  end  of  five  months  are  described 
as  follows:  "  Great  hyperplasia  and  new  formation  of 
lymph-nodes,  new  formation  of  haemolymph-nodes  in  adi- 
pose tissue,  marked  haemolysis,  eosinophils  in  the  lym- 
phoid tissues,  pigmentation  of  the  liver,  and  slight  lym- 
phoid changes  in  the  fatty  marrow."  Leucocytosis  was 
most  marked  at  the  end  of  two  months. 

From  this  summary  it  is  evident  that  two  types  of 
changes  have  been  found :  ( 1 )  A  peculiar  new  formation 
of  lymph-nodes  (Tizzoni,  Winogradow  and  Mosler) ,  prob- 
ably identical  with  the  hsemolymph-node  described  by 
Warthin,  and  (2)  an  inconstant  hyperplasia  of  preexisting 
lymph-nodes  with  reddish  or  reddish-brown  discoloration. 

As  to  the  formation  or  destruction  of  red  cells  by  the 
lymph-nodes  after  splenectomy,  divergent  opinions  are 
held.  Gibson  ^*''  and  Laudenbach,'"**  among  others,  sup- 
port the  theory  of  red-cell  formation ;  Warthin  saw  no  evi- 
dence of  this.  On  the  other  hand,  the  latter  states  that  his 
findings  indicate  that  the  splenic  functions  of  haemolysis 
and  leucocyte  formation  are,  in  the  absence  of  the  spleen, 
taken  over  by  the  lymph-  and  haemolymph-nodes.  So  far 
as  the  function  of  luemolysis  is  concerned,  this  view  is 
supported  by  Morandi  and  Sisto,'^*  who  found  in  the 
hfemolymph-nodes  of  dogs  evidence  cf  increased  haemolysis 
after  splenectomy.  According  to  Warthin,  "  the  haemo- 
lytic  function  of  the  hfemolymph-nodes  and  hyperplastic 
lymph-glands  exceeds  that  of  the  primitive  spleen,  causing 
an  excessive  destruction  of  red  cells.  The  resulting  anaemia 
is  later  compensated  for  by  an  increased  activity  on  the 


H 


168 


THE  SPLEEN  AND  ANAEMIA 


part  of  the  bone-marrow.  It  would  appear,  therefore,  that 
the  removal  of  the  spleen  leads  to  an  increased  production 
or  retention  of  some  haemolytic  agent  usually  disposed 
of  by  the  spleen.  The  effect  of  this  hremolytic  agent 
is  either  to  stimulate  the  phagocytes  in  the  htemolymph- 
nodes  to  increased  activity,  or  to  change  the  red  cells  so 
that  they  are  more  easily  destroyed  by  these  phagoc\i;es." 

This  view  is  not  shared  by  Banti,^*  who,  although  he 
considers  the  hTiiph-nodes,  liver,  and  bone-marrow  to  be 
secondary  organs  of  ha?molysis,  denies  that  they  may  com- 
pensate for  the  hemolytic  activity  of  the  spleen.  Indeed, 
it  is  upon  this  argument  that  he  bases  the  beneficial  results 
of  extirpation  of  the  spleen  in  ha?molytic  splenomegaly. 

Changes  in  thk  Lymph-nod  ,.;. — All  animals  used  in 
our  studies  of  the  effect  of  splenectomy  have  been  carefully 
examined  ^^  at  autopsy  in  the  hope  of  finding  the  ha?mo- 
lymph-nodes  occasionally  noted  by  other  investigators.  In 
this  we  have  not  been  successful,  ^ever  upon  gross  ex- 
amination have  we  found  structures  corresponding  to 
Warthin's  description,  and  the  occasional  doubtful  ha'mo- 
lymph-node  has  always  proved  upon  histological  examina- 
tion to  be  a  hannorrhagic  or  otherwise  pathologically  altered 
lymph-node.  Upon  this  point  we  have  felt  relieved  since 
Dr.  Warthin  assured  us  that  the  dog  is  a  very  unsatisfac*  ">ry 
animal  for  the  study  of  th^^  hsemolymph-node.  Still,  it  has 
been  a  matter  of  surprise  to  us  that  we  have  found  in  none 
cf  the  many  dogs  we  have  examined  the  bodies  described 
by  Tizzoni,  Winogradow,  and  Mosser. 

The  second  change  in  the  lymph-nodes — a  reddish  or 
reddish-brown  discoloration — «lescribed  by  other  observers 
we  have  frequently  seen.  More  frequently  this  has  been  a 
reddening  limited  to  the  centre  of  the  node,  at  other  times  a 


CHANGES  IN  LIVER  AND  LYMPH-NODES 


169 


diffuse  reddening.  In  animals  splenectomized  ten  months 
or  more  the  red  usually  gives  way  to  a  brownish  color, 
especially  in  the  inguinal  and  axillary  lymph-node. 

Hyperplasia  of  the  lymph-nodes  has  been  common  in 
animals  killed  shortly  after  splenectomy,  but  in  those  rep- 
resenting the  longer  periods  it  has  been  impossible  to  dis- 
tinguish any  appreciable  increase  in  size  and  certainly  no 
new  formation. 

On  the  other  hand,  the  lymph-nodes  (as  also  the  liver) 
in  a  small  group  of  animals  presented  changes  which 
appear  to  be  of  significance  in  connection  with  the  general 
problem  of  blood  destruction  in  the  absence  of  the  spleen. 
These  changes  are  (1)  a  proliferation  of  the  endothelial 
cells,  and  (2)  an  increase  in  the  phagocytic  power  of  these 
cells  for  red  blood-corpuscles. 

It  is  not  necessary  to  discuss  the  voluminous  literature 
concerning  the  destruction  of  red  cells.  This  has  been 
well  presented  up  to  1895  by  Gabbi  "'  and  up  to  1901 
by  Hunter.'**  The  more  recent  literature  has  added  little 
either  in  fact  or  theory  that  is  new.  Out  of  the  mass  of 
contradictory  statements  there  is  uniformity  of  opinion 
on  only  two  points:  (1)  That  large  endothelial  cells  of 
the  spleen  (the  red  blood-corpuscle-carrj'ing  cells)  have 
the  power  to  engulf  red  blood-cells;  and  (2)  that  the 
presence  (in  anaemia  and  malaria)  of  blood-pigment  in 
the  cells  (KupiFer's  cells)  of  the  liver  capillaries  indicates 
that  these  cells  play  some  important  part  in  the  destruction 
of  red  blood-cells.  On  the  other  liand,  it  is  not  generally 
admitted  that  the  endothelial  cells  of  the  lymph-nodes 
likewise  have  this  power.  That  phagocytosis  of  red  cells, 
wherever  it  occurs,  leads  ultimately  to  the  freeing  of 
haemoglobin,  which  eventually  reaches  the  liver  and  is 


;^C?ifl^^^^..-^:^.^s-:3'  ^^/^? 


vn 


THE  SPLEEN  AND  ANAEMIA 


transformed  into  bile-pigment,  is  the  opinion  of  all  who 
support  the  theory  that  this  mechanism  plays  a  part  in  the 
destruction  of  red  blood-cells.  There  is,  however,  no 
uniformity  of  opinion  as  to  whether  the  haemoglobin  is  set 
free  in  the  liver  from  red  cells  carried  there  by  the  phago- 
cytes or  whether  it  is  set  free  by  the  phagocytes  elsewhere 
and  carried  to  the  liver  in  another  way. 

It  is  only  with  one  phase  of  the  subject,  the  role  of 
endothelial  cells  in  engulfing  red  cells  in  the  absence  of  the 
spleen,  that  we  will  concern  ourselves  here.  Our  hypoth- 
esis is  that  in  the  absence  of  the  spleen  the  endothelial 
cells  of  the  lymph-nodes  and  liver  compensate,  at  times 
of  excessive  blood  destruction,  for  the  loss  of  similar  cells 
of  the  spleen. 

This  possibility  was  first  brought  to  our  attention  in 
the  routine  examination  of  tissues  from  splenectomized 
dogs  which  had  received  specific  haemolytic  immune  serum. 
So  striking  were  some  of  the  pictures  that  we  undertook, 
for  the  sake  of  control,  the  study  of  the  liver  and  lymph- 
nodes  from  a  number  of  normal  dogs,  of  normal  dogs  re- 
ceiving hsemolj^ic  serum,  and  of  dogs  which  had  been 
splenectomized  for  various  lengths  of  time,  but  which  had 
not  received  hctmolytic  serum. 

The  literature  of  splenectomy  offers  little  aid  in 
determining  the  histological  changes  occurring  in  the 
lymph-nodes  after  removal  of  the  spleen.  In  the  litera- 
ture at  our  disposal  no  definite  descriptions  have  been 
found  except  those  of  Warthin,  who  found  in  sheep  and 
goats  an  increase  m  the  phagocytic  power  of  the  endo- 
tiielial  cells  for  red  blood-corpuscles.  Gabbi,  who  worked 
with  the  guinea-pig,  states  that  a  transient  increase  of  the 
red  blood-corpuscle-carrying  cells  may  possibly  occur  in 


CHANGES  ES'  LIVER  AND  LYMPH-NODES  171 

early  periods  after  splenect(Mny,  but  that  after  three  to  six 
months  they  are  no  more  abundant  than  in  the  normal 
animal. 

The  IjTiiph-nodes  studied  have  been  for  the  most  part 
the  mesenteric,  gastrohepatic,  prevertebral,  and  bronchial. 
In  the  normal  animal  these  have  been  examined  more 
particularly  for  the  frequence  of  mitosis,  for  the  number 
of  endothelial  cells  in  the  sinuses,  and  for  the  presence 
of  cells  containing  red  blood-corpuscles.  Careful  study 
of  ncxles  from  five  normal  animals  showed  that  mitotic 
figures  are  found  only  after  prolonged  search  and  are 
usually  limited  to  the  follicles.  The  mmiber  of  endothelial 
cells  varies,  but  usually  is  not  great,  and  they  never  occur 
in  large  masses  in  the  sinuses.  These  cells,  however,  not 
infrequently  contain  old  blood-pigment,  and  occasionally 
a  cell  may  be  seen  containing  one  or  two  red  blood- 
corpuscles. 

The  IjTTiph-nodes  of  five  animals  splenectomized  for 
three,  four  (two),  thirty-nine  and  eighty- four  days  and 
not  subjected  to  the  action  of  haemolytic  serum  have  been 
studied  in  the  same  way.  In  two  animals  representing 
respectively  four  and  eighty-four  days  the  lymph-nodes 
differed  in  no  way  from  the  normal ;  in  the  other  animals 
mitotic  figures  were  abundant  in  the  follicles,  and  the 
endothelial  cells  in  the  sinuses  were  greatly  increased  in 
number.  Prolonged  search,  however,  failed  to  demonstrate 
mitotic  figures  in  the  latter  cells,  and,  although  they  occa- 
sionally contained  one  or  two  red  blood-corpuscles,  this 
power  of  phagocytosis  did  not  appear  to  be  greater  than 
in  the  non-splenectomized  animal.  The  increase  in  the 
number  of  endothelial  cells  was,  however,  verj'  striking. 

The  lymph-nodes  of  five  normal  dogs,  which  had  received 


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172 


THE  SPLEEN  AND  A\/EML\ 


m^- 


specific  ha>molytic  immune  serum  and  had  died  or  been 
chlorofoi-med,  after  periods  varying:  from  twenty-four 
hours  to  nine  days,  showed  tlie  lesions  asually  described 
as  common  to  various  cytotoxic  sera  ^"  and  especially  to 
lymphotoxic  sera.'  '^  These  are  (tdema.  increase  of  poly- 
morphonuclear leucocytes,  focal  areas  of  necrosis,  abundant 

TABLE  XLVII 

Changes  in  the  Lymph-nodes  Afteb  .Splenectomy  and  the  Injection  of 

HiEMOLYTic  Serum 


Experi- 

period           Period 

after  eple-  '       after 

Kffeft  of  serum 

HistoloRy 

neclomy    1      serum 

I 

3  days   36  hours 

Ha;moglobinuria 

Extreme  phagocytosis  of 

red  cells 

11 

300  (lays 

36  hours 

Severe  jaundice 

Well  marked  phagocyto- 
sis of  red  eel  s 

in 

285  days 

18  hours 

No  record 

Well  ma-ked  i)hagocyto- 
sis  of  red  cells 

IV 

225  days 

48  hours 

Ha;moglobinuria 

Moderate  phagocytosis 
of  red  cells 

V 

15  days 

3  days 

Ha?mogIoliinuria 

Negative 

VI 

27  days 

3  days 

HKinoglohinuria 

Proliferation  of  endothe- 
lial cells 

VII 

33  days 

4  days 

Jaundice 

I'roliferation  of  endothe- 
lial cells 

VIII 

65  days 

8  days 

HaBmoglobinuria 

Prohferation  of  endothe- 
lial cells 

IX 

6  days 

9  davs 

Hemoglobinuria 

Negative 

X 

3  days 

9  days 

\o  ha>moglobinuria  or 
jaundice 

Negative 

XI 

103  days 

10  days 

No    ha'moglobinuria 
(spontaneous  jaundice) 

Proliferation  of  endothe- 
lial cells 

XII 

25  days 

15  days 

Jaundice 

Proliferation  of  endothe- 

i 

lial  cells 

mitotic  figures  in  the  follicles,  and  slightly  greater  fre- 
quency of  large  endothelial  cells  capable  of  phagocytosis 
of  red  cells. 

Of  animals  that  had  been  splenectomized  and  had  re- 
ceived hirmolytic  scrum  as  well,  twelve  were  available  for 
histological  examination.  Of  these,  three  showed  no  change 
in  the  lymph-nodes  and  five  showed  a  well-marked  in- 


CHANGES  IN  LIVER  AND  LYMPH-NODES  173 

crease  in  the  number  of  endothelial  cells  in  the  sinuses, 
but  no  increase  in  power  of  phagocytosis.  In  the  four 
remaining  animals  the  sinuses  contained  a  great  number 
of  large  endothelial  cells  filled  with  red  blood-corpuscles. 
The  analysis  of  these  findings  is  somewhat  difficult,  as 
three  factors  must  bo  considered:  (1 )  The  length  of  time 
after  splenectomy;  (2)  the  lapse  of  time  between  adminis- 
tration of  hicmolytic  serum  and  the  death  of  the  animal; 
and  (3)  the  degree  of  red-cell  destruction  caused  by  the 
serum. 

These  factors  are  brought  out  in  Table  XLVII. 

From  this  analysis  it  is  seen  that  the  proliferation  of 
the  endothelial  cells  did  not  occur  in  the  animals  (V,  IX, 
and  X)  splenectomized  for  periods  of  from  three  to  fifteen 
days,  but  was  evident  in  five  (VI,  VII,  VIII,  XI,  and 
XII)  in  which  the  time  elapsing  since  splenectomy  was 
27  to  103  days.  On  the  other  hand,  the  Ivmph-nodes  of 
these  animals  did  not  present  evidence  of  increased  phao-o- 
cytosis  of  red  cells.  Whether  this  was  due  to  the  perFod 
which  had  elapsed  (three  to  fifteen  days)  since  injection 
of  serum  could  not  be  determined,  but"  this  was  probably 
tlie  case. 

Certainly  it  was  not  due  to  failure  of  haunolysis,  for 
at  least  two  of  these  animals  (VI  and  VIII)  presented 
evidence  of  extreme  blood  destruction.  That  the  period 
of  time  elapsing  may  be  an  important  factor  is  shown  by 
the  fact  that  all  animals  ( four  .  in  which  there  was  evidence 
of  extensive  phagocytosis  of  red  cells  represent  periods 
of  eighteen  to  forty-eight  hours  after  injection  of  the 
serum.  In  the  absence  of  exact  knowledge  of  the  length 
of  time  necessary  for  the  destruction  of  red  cells  by  pjiago- 
cytic  endothelial  cells,  it  is  useless  to  surmise,  but  one  can- 


M 


.J 

i  i 


r.      ,    I 


174 


THE  SPLEEN  .VND  ANEMIA 


^i^.^ 


not  escape  the  fact  that  in  this  investigation  all  evidence 
of  active  phagocytosis  is  seen  in  animals  dying  within  forty- 
eight  hours.  It  is  possible,  therefore,  that  the  destruction 
of  red  cells  by  phagocytosis  may  be  completed  within  forty- 
eight  hours,  and  this  view  is  supported  by  the  frequency 
with  which  pigment  is  found  in  the  lymph-nodes  at  later 
periods. 

It  is  also  evident  that  the  time  elapsing  since  splenec- 
tomy bears  no  relation  to  the  occurrence  of  phagocytosis 
of  red  cells,  for  the  most  marked  example  of  the  latter  was 
seen  in  a  dog  dying  three  days  after  splenectomy,  while 
moderate  and  well-ma:  ed  phagocytosis  occurred  likewise 
after  seven  and  one-half,  nine  and  one-half  and  ten  months. 

Recently  Karsner,  Amiral,  and  Bock  ^"*  have  confirmed 
these  results  and  have  added  some  interesting  observations 
concerning  the  time  element.  Their  conclusions  are  as 
follows : 

In  cats  the  same  phenomenon  of  phagocytosis  of  red 
blood-corpuscles  in  the  liver  and  lymph-nodes  takes  place 
as  in  the  dog.  In  the  series  of  splenectomized  animals 
killed  three,  six,  twelve,  twenty-four,  and  forty-eight  hours 
after  injection  we  found  at  three  hours  hyaline  thrombosis, 
large  numbers  of  mitotic  figures,  and  in  three  Ij'mph-nodes 
two  phagocytes  containing  each  one  red  blood-corpuscle 
and  showing  a  certain  amount  of  pigment  phagocytosis; 
at  six  hours  there  was  karyorrhexis  in  the  central  parts  of 
the  follicles,  marked  mitosis,  phagocytosis  of  red  blood- 
cells  and  of  pigment,  more  marked  in  the  central  sinuses 
than  in  the  peripheral  siimses.  Digestive  vacuoles  in  these 
phagocytes  contained  only  a  few  er\'throcytes.  At  twelve 
hours  there  was  marked  phagoc>i:osis  of  the  red  blood-cor- 
puscles in  the  central  and  peripheral  sinuses,  also  phage- 


CHANGES  IN  LIVER  AND  LYMPH-NODES  175 

cytosis  of  pigment  granules.     At  twenty-four  hours  the 
necrosis  in  the  follicles  did  iiot  appear  to  be  severe;  the 
phagocytosis  of  the  red  blood-corpuscles  was  seen  princi- 
pally in  the  peripheral  sinuses.  At  forty-eight  hours  there 
was  still  hyaline  thrombosis,  very  little  evidence  of  necrosis, 
marked  phagocytosis  of  pigment  both  in  the  central  and 
peripheral  sinuses.     Practically  no  red  blood-corpuscles 
were  within  the  phagocytes,  although  simple  acidophilic 
granules,  apparently  erj-throcytic  fraginents,  were  found. 
The  story  of  the  phagocytosis  appears  to  be  that  it 
begins  at  about  three  hours  after  injection  of  the  immune 
serum,  continues  progressively,  and  reaches  its  height  at 
somewhere  between  twelve  and  twenty-four  hours  after 
injection,  and  then  the  destruction  of  the  corpuscles  goes 
on,  so  that  at  forty-eight  hours  there  is  nothing  left  but 
pigment  and  corpuscular  fragments.    Furthermore,  with 
the  passage  of  time  the  individual  phagocytes  become 
more  and  more  filled  with  erythrocytes  until  about  twelve 
to  twenty-four  hours,  at  which  time  there  is  a  disappear- 
ance of  the  erythrocytes  with  the  substitution  of  the  pig- 
ment granules.    The  origin  of  the  phagocytes  appears  to 
be  particularly  the  endothelial  cells  of  the"  sinuses,  but  in 
many  of  the  lymph-nodes  it  was  found  that  the  individual 
cells  of  some  of  the  smaller  blood-vessels  were  swollen  and 
also  phagocv^ic,  and  it  is  possible  that  this  is  an  important 
matter  in  connection  with  the  origin  of  the  phagocytic  ceils 
and  also  an  important  way  of  explaining  the  presence  of 
red  blood-corpuscles  within  the  lymphatic  sinuses.    Careful 
examination  failed  to  show  anything  in  the  nature  of  rup- 
ture of  any  of  the  blood-vessels. 

Another  phase  of  Karsner's  work  had  to  do  witii  the 
question  of  h»mopsonins;  that  is,  with  the  possibility  of 


176 


THE  SPLEEN  AND  AN/EMIA 


the  spleen  having  some  relation  to  a  substance  which  ren- 
ders the  red  cells  more  susceptible,  or  otherwise,  to  phago- 
cytosis, and  the  possible  increase  or  decrease  of  such  a 
substance  after  splenectomy.  He  summarizes  ^"'*  the  re- 
sults of  this  phase  of  the  investigation,  as  follows: 

1.  Splenectomy  produces  no  change  in  ha'mopsonins 
of  the  circulating  blood  that  is  clearly  demonstrable  by 
in  vitro  tests. 

2.  The  venous  blood  returning  from  the  kidney  and 
from  the  spleen  ana  the  venous  blood  of  the  portal  vein, 
of  the  right  auricle,  and  of  the  left  ventricle  showed  the 
same  content  of  ha?mopsonin. 

3.  PLxtracts  of  washed  spleen,  kidney,  pancreas,  and 
liver  showed  no  influence  over  the  phagocytic  activity  of 
the  corpuscle,  serum,  and  exudate  mixture  used  in  the 
opsonic  work. 

4.  Extracts  of  the  lymph-nodes  of  splenectomized  dogs 
and  the  extract  of  the  lymph-nodes  of  normal  dogs  have 
no  influence  over  the  phagocytic  mixture  mentioned  under 
heading  3. 

CiiANCJES  IN  THE  LivEK. — Examination  of  the  stellate 
endothelial  cells  (KupfFer's  cells)  of  the  liver  ^''^  has  been 
rendered  difficult  on  account  of  the  intense  congestion  and 
abundant  necrosis  which  occur  in  the  liver  after  the  admin- 
istration of  h.TMiolytic  immune  serum.  For  this  reason  we 
have  not  always  been  able  to  correlate  the  evidence  of  pha- 
gocytosis in  the  liver  with  tlie  lesion  descril)ed  in  the  lymph- 
nodes  during  the  early  (<^orty-eight  hour)  period.  Definite 
evidence,  however,  of  phagocytosis  has  been  found  in  four 
animals,  representing  periods  of  one,  two,  eight,  and  nine 
days  after  the  administration  of  serum,  and  representing, 
respectively,  periods  of  three,'^-'  sixty-five,  and  six  days 


CHANGES  IN  LIVER  AND  LYMPH-NODES 

after  splenectoniy.  Also  in  a  fif'tli  animal,  twenty-five  dt.ys 
after  splenectomy  and  fifteen  days  after  the  administration 
of  the  serum,  the  cells  of  the  capillaries  contained  small 
balls  of  yellow  pigment,  apparently  representing  altered 
luvmoglobin. 

As  controls  we  have  examined  the  livers  of  severaJ  nor- 
mal dogs  and  of  nine  splencctomized  dogs  not  receiving 
serum,  hut  without  finding  evidence  of  phagocytosis  on 
the  part  of  the  cells  of  the  liver  capillaries,  or  of  prolifera- 
tion of  these  cells.  The  sj)lenectomies  in  this  series  repre- 
sented periods  of  from  three  to  eighty-four  days;  rive  under 
ten  days  and  three  over  twenty  days. 

Likewise  we  liave  examined  the  livers  of  nine  normal 
dogs  receiving  ha-molytic  serum.  In  two  of  these  the  endo- 
thelial cells  appeared  to  be  increased  somewhat  in  number, 
but  no  undoubted  evidence  of  phagocytosis  could  be  ob- 
tained. All  other  livers  examined  showed  no  changes  in 
the  cells  of  the  capillaries. 
]MrcH()CHEMiCAi.  Tksts  lOR  Ihox  in  Lymph-xodes 

AND  Livj:r 
Warthin,  in  his  study  of  the  lymph-nodes  and  Iuppio- 
lymph-nodes  of  sheep  and  goats,  found  in  these  organs, 
several  months  after  splenectomy,  evidence  of  increased 
blood  destruction.  This  we  have  observed  in  the  dog,  in 
so  far  as  it  is  shown  by  phagocytosis  of  red  cells,  only  after 
the  administration  of  a  hannolytic  poison;  in  the  ordinary 
course  of  events,  no  inci-eased  ])hagocytic  activity  on  the 
part  of  the  endothelial  cells  of  the  lymph-nodes  of  the 
splenectonu'zed  animal  is  seen.  This  obsen-ation  we  have 
confirmed  by  examining  a  numl)er  of  lymph-nodes  and 
liver  by  the  usual  microchemical  method  ,if  demonstrating 
the  presence  of  iron.    The  lymph-nodes  of  fourteen  sple- 

12 


'I 


I 

I 

ii 
I 


^  I  SI 

'  t  11 

i 


178 


THE  SPLEEN  AND  AN.EMU 


nectoiiiized  dogs  showed  a  considerable  amount  of  iron  in 
three,  slight  amounts  in  five,  and  none  in  six.  The  animals 
examined  represented  periods  of  eleven  days  to  twenty- 
two  months  after  splenectomy.  In  the  lymph-nodes  of 
fifteen  normal  animals  similarly  examined  moderate 
amounts  of  iron  were  found  in  eight,  slight  amounts  three 
times,  and  in  four  none.  It  is  evident,  therefore,  that  in 
the  dog  the  iron  content  of  the  lymph-nodes  after  splenec- 
tomy differs  little  from  normal.  The  liver  likewise  shows 
no  increased  deposition  of  iron.  Of  fourteen  livers  from 
splenectomized  dogs,  four  showed  slight  deposition  of  iron 
in  Kupffer's  cells,  while  ten  showed  none.  At  the  same 
time  the  livers  of  six  normal  dogs  were  similarly  exam- 
ined; in  three  slight  deposits  of  iron  were  found,  and  in 
three  none. 

Protocols  illustrating  the  histological  changes  in  the 
lymph-nodes  and  liver  follow: 

Dog  32. — Splenectomy  was  performed  under  ether 
anaesthesia  on  July  19,  1911;  on  March  8,  1912,  specific 
hasmolytic  immune  serum  was  injected  intravenously.  The 
red  cells  dropped  within  three  hours  from  6,120,000  to 
5,200,000  per  cubic  millimetre,  and  the  haemoglobin,  after 
twenty  hours,  to  42  per  cent.  Haen  Dglobinur'a  was  pres- 
ent, and  death  occurred  after  forty-eight  hours. 

Histology. — The  liver-cells  are  pale,  granular,  stain 
poorly,  and  present  here  and  there  small  areas  of  focal 
necrosis.  The  capillaries  are  dilated  and  contain  much 
granular  material  and,  as  seen  by  the  low  power,  numerous 
isolated  round  and  oVal  clumps  of  red  blood-corpuscles. 
By  higher  power  of  the  microscope  these  clumps  of  red 
cells  are  found  to  be,  in  large  part,  within  endothelial  cells 
(Plate  I.  Fig.  4).  Some  of  the  red  cells  stain  well  with 
eosin.  others  appear  as  shadows.    Other  endothelial  cells 


CHANGES  IN  LIVER  AND  LYMPH-NODES 


179 


are  seen  'Aliich  contain  mere  fragments  of  red  cells  or 
masses  of  granular,  yellow  pigment,  or  large,  yellow  hya- 
line balls  of  apparently  fused  red  cells.  Attempts  to  dem- 
onstrate similar  phagocj-tic  cells  in  the  large  vessels  of  the 
liver  and  of  other  organs  failed;  they  were  present,  how- 
ever, in  the  sinuses  of  the  lymph-nodos. 

Dog  34. — Splenectomy  was  performed  under  ether 
ansesthesia  on  March  11,  and  hemolytic  serum  adminis- 
tered intravenously  on  March  14.  Death  occurred  on 
March  15,  after  reduction  of  red  cells  to  1,960,000  and 
hemoglobin  to  57  per  cent.    Haemoglobinuria  was  marked. 

Histology. — A  mesenteric  lymph-node  shows  hemor- 
rhage, oedema,  and  extensive  infiltration  with  polymor- 
phonuclear leucocytes.  The  sinuses,  both  peripheral  and 
central,  are  closely  packed  with  large,  pale,  endothelial 
cells,  nearly  all  of  which  contain  red  blood-cells,  a  single 
high-power  field  showing  thirty  to  forty  phagocytic  cells 
(Plate  I,  Figs,  l  and  2).  The  number  of  engulfed  red 
blood-cells  varies,  but  is  usually  large,  ten  to  twenty  not 
infrequently  being  found  in  a  single  cell.  In  many  en- 
dochelial  cells,  on  the  other  hand,  the  red  blood-cells  have 
fused  to  form  large,  round,  or  oval  hyaline  masses  still 
staining  deeply  with  eosiii.  Between  the  phagocytic  cells 
is  much  granular,  eosin-staining  material  suggesting  dis- 
integrated red  cells,  mingled  with  serum,  through  which 
lom  irregular  threads  of  fibrin.  Here  and  there  in  the 
follicles  are  small  areas  of  necrosis.  Moderate  leucocytic 
infiltration  is  seen  throughout  the  section.  Phagocytic 
cells  cannot  be  demonstrated  in  the  blood-vessels  or  in  a 
tangle  of  lymphatic  vessels  present  at  one  side  of  the  node. 

Other  IjTnph-nodes  (gastrohepatic,  prevertebral,  and 
bronchial)  present  the  same  lesions. 


■:| 


tl 


180 


THE  SrLEEX  AND  AN/EMIA 


The  liver  of  this  animal  showed  widespread  necrosis, 
hut  in  the  non-necrotic  areas  phagocytic  endothelial  cells 
are  found  in  the  capillaries  (Plate  I,  Fig.  3). 

SUM.MAUY 

In  a  Inrfre  proportion  of  dogs  that  have  hccn  splenec- 
toniized  for  periods  of  two  weeks  or  more  one  finds  a  great 
increase  in  the  nuniher  of  endothelial  cells  of  the  lymph- 
nodes.  In  most  spleneetdtuized  dogs  that  siiceuml)  to  an 
injection  of  haMiiolytic  immune  serum  within  forty-eight 
hours  tliL'  sinuses  of  the  lymph-nodes  contain  large  imm- 
hers  of  endotlielial  cells,  pliagocytic  for  red  hlood-cells. 
Tliis  is  not  seen  in  normal  dogs  receiving  h;cmolytic  serum. 
I^ikewise  a  similar  power  of  phagocytosis  is  seen  fre- 
quently in  the  stellate  colls  (KupfFer's)  of  tlie  capillaries 
of  the  liver.  Both  in  the  lymph-nodes  and  the  liver  these 
cells  a})pear  to  he  formed  in  ffitu:  we  find  no  evidence  that 
they  have  hecn  transi)orted  to  these  organs. 

Such  findings  suggest  the  development  of  a  compen- 
satory funetion  on  the  part  of  the  lymph-nodes  and  pos- 
sibly the  liver.  Xormally  the  spleen  contains  cells  which 
have  the  power  to  engulf  and  presumably  to  destroy  the 
red  blood-corpuseles.  In  certain  patliological  conditions 
this  function  is  f]'e(|uently  greatly  augmented  and  n)ay 
sometimes  he  shared  by  the  lymph-nodes;  for  example,  in 
tyi>hoid  fever,  as  was  first  clearly  shown  by  ^Mallory.""" 
Our  observations  suggest  that  in  the  absence  of  the  s})leen 
this  function  of  forming  red  blood-corpuscle  {)hagocytic 
cells,  normally  a  minor  activity  of  the  lymph-nodes,  be- 
comes highly  developed  in  the  latter  organs,  and  that  in 
times  of  stress  tiicse  cells  and  the  stellate  cells  of  the  liver 
tlnis  assume,  in  part  at  least,  the  function  of  destroying 
red  l)lood-corpuscles  by   phagocytosis. 


CHAPTER  VIII 


MKTAIUJLISM  STUDIKS  ON  THE  DOCi  IJEFORE  AND 
AFTER  SPLENECTOMY 

Although  early  in  our  work  we  studied  the  influence 
of  splenectomy  npoii  iron  metabolism  ^see  p.  112),  it  did 
not  at  that  tinu;  set  iii  advisable,  on  account  of  the  generally 
negative  results  of  others,  to  study  the  efFect  of  splenec- 
tomy upon  nitrogen  metabolism.  Later,  however,  when 
interested  in  the  influence  of  diet  in  connection  with  the 
ana'mia  of  splenectomy,  we  became  aware  of  the  obsen-a- 
tions  of  Kichet.''^  which  seemed  to  iudicate  that  in  order 
to  maintain  the  weight  of  a  splenectomized  dog  a  much 
larger  amount  of  food  is  required  than  is  tlie  case  with  the 
normal  dog. 

These  studies  suggested  to  us  a  possi1)ie  explanation  of 
the  contradictory  and  confusing  results  obtained  in  our 
dietary  studies,  and.  as  nitrogen  metabolism  had  never  been 
studied  in  animals  in  nitrogen  equilibrium,  we  undertook 
a  detailed  investigation  in  the  hope  of  arriving  at  some 
detinite  conclusion  concerning  (1)  the  influence  upon 
jnetabolism  of  the  absence  of  the  spleen,  as  contrasted 
witbi  (2)  the  influence  on  metabolism  of  the  ana^nia  which 
usually  follows  splenectomy. 

Previous  Ixvkstioattoxs 

Paton's  "^  investigation  included  studies  of  t!;c  nitro- 
gen metabolism  and  the  elimination  of  salts  in  a  single 

isi 


Hi:     '. 


t 


,,!■-. 


182 


THE  SPLEEN  AND  .VN.EMIA 


dog  before  and  after  splenectomy.  Obser\'ations  were 
made  during  fasting  and  on  (1)  meat,  (2)  oatmeal  and 
milk,  and  (3)  rich  nuclein  diets.  The  first  post-splenec- 
tomy  metabolism  study  was  made  twenty-six  days  and  the 
last  four  months  after  the  operation.  Paton's  general 
conclusion  h  that  under  the  various  conditions  of  his  experi- 
ments splenectomy  causes  no  essential  difference  in  the 
course  or  nature  of  the  metabolism. 

In  Richet's  first  investigation^"^  nine  splenectomized 
dogs  were  contrasted  with  six  normal  dogs.  No  metabolism 
studies  and  no  examinations  of  the  blood  were  made.  Con- 
clusions were  based  on  records  of  food  taken  and  the  weight 
of  the  animals  at  various  inten'als.  The  increased  con- 
sumption of  food  by  the  splenectomized  animals  is  thought 
by  Richet  to  be  due  to  an  increased  catabolism  in  those 
animals  and  not  to  any  disturbance  of  digestion.  In  a  later 
report  ^''*  he  refers  to  studies  of  seventeen  splenectomized 
dogs,  of  which  five  were  under  obser\'ation  for  about  two 
years,  and  confirms  the  conclusions  of  his  earlier  report. 
In  this  connection  it  is  a  matter  of  importance  that  the 
conclusions  are  based  on  the  averages  of  two  groups  of  dogs 
of  widely  different  weights.  Richet  has  not  contrasted 
splenectomized  dogs  of  given  weight  with  normal  dogs  of 
the  same  weight,  but  if  one  selects  from  his  tables  dogs 
of  the  same  weight  the  differences  in  food  consumption  are 
found  to  be  very  slight.  Only  two  dogs  were  studied  both 
before  and  after  splenectomy. 

Mendel  and  Jackson,^*^  who  investigated  the  relation 
of  the  spleen  to  purin  metabolism,  found  that  in  splenec- 
tomized dogs  and  cats  no  changes  occurred. 

Verzar*'*''  has  found  that  extirpation  of  the  spleen  in 
dogs  has  no  appreciable  effect  upon  the  respiratory  gas 


METABOLISM  SI UDIES  ON  THE  iXA} 


183 


exchang'e.  A  siniiiar  c(jnclusion  was  reached  by  Koren- 
chevski  ^"  as  regards  both  gaseous  and  nitroginous  nietab- 
oHsm.  No  other  experimental  studies  of  the  influence  of 
splenectomy  are  available,  except  the  brief  note  of  Austin 
and  Ringer^'  to  the  effect  that  in  the  dog  the  absence  of 
the  spleen  does  not  in  any  way  modify  the  course  of  the 
glycosuria  caused  by  pholornizin. 

Methods 
The  four  dogs  used  in  this  study  were  placed  upon  a 
constant  diet  of  beef  (usually  beef-heart),  lard,  and  sugar, 
the  amounts  of  each  of  which  constituents  varied  accord- 
ing to  the  caloric  needs  of  each  dog.  The  standard  diet  con- 
tained 0.4  gm.  of  nitrogen  per  kilo,  and  70  calories  per  kilo, 
of  body  weight.  A  small  amount  of  sodium  chloride  was 
given  each  day,  and  a  suificient  amount  of  bone-ash  was 
added  to  ensure  well-formed  faeces.  The  water  intake  for 
each  day  was  constant.  To  some  animals  the  beef-heart 
was  given  raw;  in  other  instances  it  was  boiled.  After 
one  or  two  weeks  on  the  special  diet,  if  the  weight  of  the 
animal  remained  constant,  a  preliminary  metabolism  study, 
covering  a  period  of  seven  days,  was  made.  If  the  results 
of  this  were  satisfactory,  the  animal  was  then  splenecto- 
mized  and  the  metabolism  studies  resumed  at  various  inter- 
vals after  the  operation.  In  each  experiment  the  diet  after 
operation  was  always  the  same  as  before,  and  was  con- 
tinued without  change  in  the  intervals  between  periods  of 
metabolism  study.  Analyses  were  made  of  all  foods  for 
fat  and  total  nitrogen.  During  the  periods  of  study  the 
animals  were  kept  in  the  usual  metabolism  cages.  They 
were  catheterized  at  the  enl  of  every  twenty-four  hours 
and  the  fwces  marked  by  cv  rmine. 


i 


•! 


i 


'i 


184 


THE  SPLEEN  AND  ANvEMIA 


In  the  analysis  of  the  urine  the  total  nitrogen  was 
determined  by  the  Kjeldahl-(iunning  method,  ammonia 
by  Folin's  metliod,'^'  creatine  and  creatinine  by  Folin's 
method,'-'  and  tlie  hydrogen  ion  concentration  according 
to  Henderson's  techniciue.'"'  In  the  study  of  faeces  the 
Kjeldahl-Gunning  methml  was  used  for  total  nitrogen, 
the  Folin-Wentwortli  niethod  for  fat,'"-  and  Neumann's 
metliod"'  for  iron. 

The  removal  of  llic  spleen,  an  essentially  bit  nlless 
operation,  was  done  uiu'er  ether  aiuesthesia. 


HKsri;rs 

The  details  of  our  studies  of  nitrogen  metabolism  are 
shown  in  Tables  XLVKi.  to  LI.  and  of  fat  metabolism  in 
Tabic  L II. 

Niirogcn  MetahoUum, — Table  XLVIIl  represents  the 
earliest  period  of  metabolic  study  (three  days)  after  sple- 
'leetomy.  The  animal  showed  no  loss  of  weight,  no  ill- 
effect  of  the  operation,  and  the  conditions  were  therefore 
ideal  for  the  detection  of  any  slight  early  changes  in  metab- 
olism which  might  be  due  to  the  absence  of  the  s])leen. 
Xo  variations  in  nitrogen  partition  were  observed,  how- 
ever, and  the  nitro;^en  e(iiiilil)rium  was  maintained:  an 
average  daily  balance  before  operatitm  of  0.4..5  gm.  and 
after  operation  of  0.40  gm. 

Table  XlilX  sliows  practically  the  same  results,  thir- 
teen days  and  eight  weeks  after  splenectomy.  The  animal 
was  in  nitrogen  e(iuilibrium  before  si)Ienectomy,  and  main- 
tained that  condition  after  splenectomy.  The  general 
metabolism  shows  entirely  normal  results.  The  utilization 
of  nitrogen  was  in  no  way  interfered  with:   it  was  94  per 


METABOLISM  STUDIES  OM  HIE  DUG 


185 


cent,  before  operation  aiid  95  and  93  jKir  cent,  in  the  post- 
splenectoniy  periods. 

In  Table  L,  wliich  presents  observations  two,  six,  ami 
ten  weeks  after  splenectomy,  the  results  in  the  third  ami 
fourth  periods  (sixth  and  tenth  weeks)  are  similar  to  tliose 


Do<i 


TABLE  XLVIII 

XiTiifJCKN  Mf:tahoi,ism  HKFf)RE  Axn  Tfikke  Days  After 


M'I.ENKCTOMy 


Date 


Urine 


Foil. 
M.ir. 
Mar. 
Mar. 
Mar. 
Mar. 
Mar. 


y. 

kj.    I  j 

in.o!  i.so' 
i().s:4.s(t' 

lO.S  4.S0 

in.><  4.s(» 
in.s:  i.sn 
io.<)  4. so 

10.9i4.S0 


I    0)  d 

!  to 


cc. 
20.i 
17.') 
•J2-) 
■22.-) 
KH) 
•2IM) 
220 


10 
29 
.'U 
37 
3S 

:i7 

40 

27 


i-S 

cr 

a 

y. 

e^ 

.s  c 

s: 

=  '" 

H 

gm. 

iVM) 

.■u.-i 

<    j    o 


AvcraKo.  10.8;  4.80]  219     3o 


ym.  i  pm.  ijn 
Arid  (i.ltO '.■!.(.-,  0.13  n.2sn0.47S 
A(icl  it)..'>()  :!.7()!().1.5  0.2700.3.")7 
Aoi.l  UVM)  :i.4  110.12  0.2S9,0.32(i| 
Ari.l  |i).9()  o..'-)7|0.13l0.2,S50.321 
Acid  |().!K)  :!.«.■): 0.1 4  n.28'.10.3:j.-) 
Ac',<]  !(i.'ii)  ;f.s(>  (1.14 '/..rsiio.^ir)! 
Aciil  |t).!h!  4.02|;<.12  0.2790.3 

!o.84|3.fl2!o.l3  0.2S4  0.3(il 


I 


am. 
0.73 
0.73 
0.73 
0.73 
0.73 
0.73 
0.73 

0.73 


4.  IS  +0.02 
4.09  +0.71 
4.17  +0.(13 
4.30  +0.."iO 
4.3S  +0.42 
4. ,59  +0.21 
4.7.')  I +().(),-) 

4.3.5;+0.4o 


Mar. 

Mar. 
M:ir. 
M.ir. 
Mar. 
Mar. 
Mar. 
^lar. 


Splcncctomj' 


AvcraKt' 


10.S|4.S0  l.-)0 
lO.S  I.SO  220 
10,9J4.S0  2.35 


10.9 
10.<) 
10.9 
11.0 


I.SO  ISO 
4. SO  I  1,3,5 
4.S0J  lOTi 
4.S0  210 


4.5 
3.) 
37 
40 
4.-) 
37 
42 


A,kI 
Acid 
Acid 
Acid 
Acid 
Acid 
Acid 


10.9!4.S0   IS,-)  I  40 


,(5.15  li.so 

|()..50  3.92 

lajtO  3.'.t() 

!  (1.50  4. OS  I 

.().!.-)  3.<.t5| 

!().15  3.3() 

j0.90  3..-)3 

!  0.41 '3.81' 


O.ISO 
0.1.-)0 

0.14:0, 

0.13  0, 
0.1.5  0, 
0.130 

o.os  to, 

-    -i- 

0.10  0, 


3110 
3110 
.3320 
3020 
2S<H) 
2S90 
3110 


.310  0 
310  0 
2S.5!  0 
320  0 
2()7() 
2,59' 0, 
2s:i  0. 


.53  4 
-53  4 
,53  i  4 
,53  4 
53:4 
53  i  3 
.53 1 4 


.39+0.41 
45  +0.3.5 
.4!*  +0.31 
.61  +0.19 
4S  +0.32 
,S!»  +0.!>1 
.(Mi  +0.74 


3000.291  0..53 14.34+0.46 


*  DiiM :    rnw  h-.-ef,  !">()  (rrn,;  lard,  50  t^m.;  eupar,  ."0  gm. 
t  KxprcHK(jd  a.4  neRutivc  lo^nritliniH, 


shown  in  Tables  XLVIII  and  XI.IX.  In  the  early  period 
after  splenectomy,  however,  this  animal  showed  a  loss  of 
appetite  which  caused,  durinii-  the  two  weeks  following? 
operation,  a  loss  in  \veip;ht  of  1.4  kilos.  This  loss  of  appe- 
tite was  not  due  to  infection  or  other  post-oi^erative  dis- 


i 


M. 


186 


THE  SPLEEN  AND  ANAEMIA 


turbances,  but  appeared  to  be  due  rather  to  a  dislike  of  the 
lard  ill  the  diet.  When  the  lard  was  cut  out  of  the  diet 
the  animal  ate  readily,  and  later,  -Rhen  the  lard  was  again 
added,  no  trouble  was  experienced.  As  may  be  seen  in 
Table  LII,  this  was  the  only  animal  which  showed  a  high 


DoQ  48. 


TABLE  XLIX 

NiTROGKN  Metabolism  Before  and  Two  and  Eight  Weeks  Aiter 

Splenectomy 


1 

• 

Urine 

z 

3 

5 

03* 

a 

c 
c 

Dat« 

a 

3 

o 
S 

a" 

a 

0 

"3 

o 
H 
S 

a 

•a 

3J 

a 

g 
J 

as 
.2 

is 

y. 

■< 

73 

X 

«    *" 

H 

< 

O 

o 

U< 

z"" 

z 

ka. 

ce. 

10 

gm. 

gm. 

gm. 

gm. 

gm. 

Nov.    16 

13.4 

.5.60 

175 

56 

Acid 

0.70 

5.35 

0.38 

0.30010.358 

0.34 

5.69 

-0.09 

Nov.    17 

i;?4 

.5.60 

2.50 

47 

.•Vcid 

6.90 

5.48 

0.37  0.3380.195 

0.34 

5.82 

-0.22 

Nov.    IS 

13.4 

5.60 

225 

60 

Acid 

6.70 

4.91 

0.38  9.3.520.480 

0.34 

5.2.5 

+0.35 

Nov.    19 

1.3.4 

5.60 

210 

43 

Acid 

6.80 

5.33 

0.37  0.3680.427 

0.34 

5.C7 

-0.07 

Nov.   20 

13.4 

5.(>0 

200 

44 

Acid 

6.90 

4.80 

0  34 

0.3610.467 

0.34 

6.14 

+0.46 

Nov.   21 

13.4 

5.60 

Zm 

46 

Acid 

6.90 

4.91 

0.31 

0.3&80.408 

0.34 

5.25 

+0.35 

Nov.   22 

13.3| 

5.60 

265 

37 

Acid 

6.90 

4.77 

0.27  0.385 

0.597 

0.34 

5.11 

+0.49 

Average . 

13.4,5.00 

223 

46 

6.83 

5.08 

0.35 

0.353[o.419  0.34 

5.42 

+0.18 

Nov.   24 

Splenectomy 

Dec.      7 

13.2 

5.60 

195 

55 

Acid 

7.14 

5.19 

0.31 

0.340 

0.575 

0.30 

5.49 

+0.11 

Dec.      8 

13.1 

.5.60 

280 

35 

Acid 

6.00 

5.36 

0.34 

0.308 

0.513 

0.30 

5.66 

-0.06 

Dec.      9 

13,1 

5.60 

290 

33 

Acid 

6.90 

4.95 

0.29 

0.352 

0.630 

0.30 

5.25 

+0.35 

Dec.    10 

13.1 

5.t)0 

265 

39 

Acid 

6.80 

4.65 

0.29 

0.308 

0.513 

0.30 

4.96 

+0.64 

Dec.    11 

13.1 

5.t)0 

235 

.38 

Acid 

6.80 

4.38 

0.29 

0.324 

0.527 

0.30 

4.68 

+0.92 

Dec.    12 

13.1 

5.60 

295 

30 

Acid 

6.80 

4.40 

0.27 

0.329 

0.5.58 

0.30 

4.70 

+0.90 

Dec.    i;i 

13.1 

5.60 

24.- 

35 

.\cid 

6.80 

4.52 

0.23 

D.385 

0.672 
0.570 

0.30 

4.82 

+0.78 

Avemgc 

13.1 

5.00 

256 

39 

6.75 

4.78 

0.29 

0.3,52 

0..30 

5.08 

+0.51 

Jan.     18 

13  6 

5.70 

275 

30 

Acid 

6.80 

4.46 

0.22 

0.3.55 

0.398 

0.40 

4.86 

+0.84 

Jan.     19 

13  6 

5.701210 

44 

Acid 

6.80 

4.32 

0.24 

0.346 

0.382 

0.40 

4.72 

+0.98 

Jan.     20 

13.ft 

5.70 1  310 

20 

Acid 

6.70 

4.58 

0.22 

0.364 

0.361 

0.40.4.98 

+0.72 

Jan.     21 

13..T 

5.70  300 

39 

Acid 

6.80 

4.92 

0.21 

0.355 

0.474 

0.40 

5.32 

+038 

Jan.     22 

13.'-, 

5.70 '2.50 

35 

Acid 

0.70 

4.49 

0.24 

0.311 

0.362 

0.40 

4.89  -1-0.81 

Jan.     Zi 

13  4 

5.70  300 

39 

.A,cid 

6.5K) 

.5.12 

0.23 10.337!0. 463 

0.40 

5.52  +0.18 

Jan.     24 

13.4 

5.70  300 

39 

Acid 

6.90 

5.51 

0.22  0.326 

0.405 
0.406 

0.40 

6.91  -0.21 

Average  . 

13.5 

5.70  278 

35 

6.80 

4.77 

0.22  0.342 

0.40 

5.47J+0.53 

•  Diet:  rnw  hf-<  hc-rt,  2nO  nm  ;  Isrd,  fiO  «m.;  aug»r,  fiO  gm. 
t  Expressed  u  negalive  loaarithma. 


3VIETAB0LISM  STUDIES  ON  THE  DOG 


187 


neutral  fat  content  in  the  faeces,  though  what  relation  there 
may  be  between  tliis  and  the  dislike  of  fat  is  not  evident. 
The  practical  result  of  this  loss  of  weight  aft«r  splenectomy 
was  a  moderate  retention  of  nitrogen  in  the  first  post- 
splenectomy  metabolism  period.  However,  in  the  third 
period,  when  the  animal  had  returned  ^o  exactly  the  same 
weight  as  before  operation,  nitrogen  equilibrium  was  again 
maintained.  It  would  seem  conclusive,  therefore,  that  the 
loss  of  weight  and  nitrogen  retention  of  the  earlier  periods 
were  due  to  an  influence  other  than  the  absence  of  the 
spleen.    It  is  of  interest  that  this  dog  excreted  no  creatine. 

In  the  experiments  thus  far  presented  there  is  no  evi- 
dence that  the  absence  of  the  spleen  influences  in  any  way 
nitrogen  metabolism.  In  a  fourth  animal,  however,  the 
results  were  discordant. 

This  animal  (Table  LI)  had  serv^ed  as  a  control  for 
the  blood  counts  of  the  three  animals  discussed  above,  and 
up  to  the  time  of  our  foreperiod  had  been  for  '  welve  weeks 
on  an  adequate  constant  diet,  as  was  the  case  in  the  other 
animals.  Like  Dog  52,  this  animal  received  boiled  meat 
as  a  part  of  the  dietarj-.  The  effect  of  splenectomy  on 
the  nitrogen  metabolism,  ten  days  after  the  operation, 
was  very  slight,  but  a  nitrogen  equilibrium  of  +0.48  gm. 
per  day  was  changed  to  one  of  — 0.18  gm.,  figures  not 
beyond  the  range  of  normal  variations,  but  which,  in  the 
light  of  changes  to  be  discussed  later,  are  suggestive  of  the 
influence  of  anemia.  At  a  later  period,  three  months  after 
splenectomy,  the  animal  had  not  regained  the  slight  loss 
(0.5  kilo.)  in  weight,  but  it  appeared  to  be  in  excellent 
condition  and  the  amemia,  which  had  existed  for  several 
months,  was  improving.  The  plus  balance  of  1.10  gm.  of 
nitrogen  per  day  (upon  a  slightly  higher  nitrogen  intake) 


m    i 


188 


THE  SPLEEN  ^NJS'D  AN/EMLV 


TABLE  L 
Dog  52.     Nitrogen  Metabolism  Bkkokk  and  Two, 

AfTER   .Sl'LENEOTOMV 


Six,  and  Ten  Weeks 


Date 


Nov. 
Xiiv. 
Nov. 
Xciv. 
Nov. 
Nov. 
Dee. 


lO.S 
ilO.8 
lO.S 
lO.S 
lO.S 

'  lo.s 

lO.S 


Average 


Dec. 


Avcragf 


Avorag(! 


Yeh.  10 

Fell.  1 1 

Feb.  12 

Fel).  i:i 

Fell.  U 


4.77 
4.77 
4.77 
4.77 

4.77 
4.77 

4.77 


Urine 


!     o 


« 

1 

'i 

c 

a 

a  ! 

'A 

<   1 

cc. 

170 
KiO 
225 
170 
ISO 
21,) 
IGO 


10 
44 

44 
33 

as 

4H 
40 
43 


10.Sj4.77|l83 


44 


-.  2  I 


Acid 
.Vcid 
Aeid 
Acid 
Acid 
Acid 
Acid 


!         I  am. 
:0.-)0  4.17 


10..5() 
!c..")0 
0..-)0 

!  t)..oi  I 


y. 

« 

c 

a 

"c 

t 

a 

E 

K 

< 

O 

:;m. 

iim. 

0.30  o.3r,s' 

0.20  ().:',7.V 

4.2:i 
i.4'.J|0.23  0.3t;,S, 
t.."!")  0.2  J  0.3(JS' 
4..")  0.2.J  0.3G.S 
t.GS  0.2.J|0,3.")N' 
4.41  0.2.3  0.351 


ym 

None 
None 
None 
None^ 
None, 
None, 
None 


tjm 

0.3S 
0.3S 
0.3.S 
OMS 
0,3> 
0.3S 
0.3S 


.^ 
A 


-\ 

[    U^' 

4.5S  -rO.22 
4.01  +0.16 
4.87  -0.10 
4.93  -0.16 
4.93: -0.16 
5.00,-0.29 
4.821-0.05 


|0..")0:  1.44,0.25i0.3(i.5| 
Splenectomy 


0.3S 


4.,S2  -0.05 


9.4  4.70 

225 

23 

9.4  4.70 

1.^0 

39 

9.5  4.70 

115 

43  1 

9.5  t.70 

210 

35 

9.1)  1.70 

S5 

53  ! 

9.7,4.70 

275 

20  j 

9.-;  t.70 

175 

30  1 

9.S  4.70!  225 

25 

.Void  |0.90i2.75  0.16  0.213Nonc0.44i3.19l  +  1.51 

Aci.l  ](i..5'.)  3.73  0.25  0.321  None  0.444. 171+0.53 
Acul  ;ti.s0  2.99  0.15  0.2,sl  .None  0.14  3,43i  +  1.27 
Acid  O.SO  2.79  0.15  0.2>9 None  0. 14  3.23l-rl.47 
.\cid  '(;..'iO  2.4S  0.20 ').21t.-,No!!e  0.4  1  2.92'  +  1.7S 
.\cid  r,.70  2.79  0.2.')  0.2in  .\one  0.44,3.23  +1.47 
Acid  (i.70  2.52  0.23  0,2s<l  None  0.44 '2.1iti:  +  1.74 
.Vcid     O.bO  2.t5,S  0.25,0.311  None  0.44  3.32i  +  1.38 


4.70!  ISO  !  34 


4.40  235 
t.40'  190 
1.40 1  210 
1.10  l.SO 
!.40:  175 
4.10  225 
4.40  205 


10.:;.-,4.40!203 

.s'  l.io'  ItiO 
..S!4.I0|215 
.SI  l.lOi  220 
S  4.10  2(H) 
.9  4.10  l',)0 


lj.7I2.S7  0.21  0.2.S7 


28 
35 
35 
42 
3!  I 
35 
29 


■  Acid 
.\cid 
Acid 


O.00|3.:?5  0.27  0.311  None 0.48 
tj..30  3.3S '  0.04  o.;n )  None  OAS 
ii.15  3.00  0.2tiO..;il.\oi.c0.4> 
,Vcid  :().30  3.45  0.22  0.324  None  0.4s 
,Vcid    0.30;3..")4  '0.25  0.:i2l  .\i.i;c  0.4> 
■      '    (1.70  3.3s  0.25  0.311  N<inc  0.4S 
I  0.30, 3.57 10.20  (O.31I  None  0.4S 

|c.29  3.4G'0.250.31S  ().48 


AcK 
Aci< 


0.44  3.31; +  1.39 


3.S  1+0.59 
3. SO, +0.54 

4.0s  j +0.32 
3.93l-r0.47 
1.021+0.38 
3..Sti:+0.54 
+0.35 


4.05 

3.94 


25 
22 
27 
32 


Averatte.  10.8i4.10!  197  j  28 


Acid 
Acid 
Acid 
Acid 
Acid 


+0.4; 


(i.90  2.9G  0.23  0.225  None  0.11  3.40  +0.70 
:  G.SO  3.11, 0.25  0.22S  None  0.44  i  3. .55 '  +0..55 

G.SO|3.23j0.20 10.23 1  None  0  44  3.071+0.43 
l6..S0':!.20i0.19  0.2,34  None  0.44  3.G4I+0.46 

G.S0J3.4!  0.18JO  231  None().44  3.SS, +0.22 

|f..82;3.19  0.21  C23(^'  { 0.44] 3X)3j +0.47 


•Diet:    boiU 


1  hi'.'f  hpart.  100  gm  ;  lard,  "0  gm.;  sugar,  50  gm. 
uutfative  logarithma. 


METABOLISM  STUDIES  ON  THE  DOG 


189 


ill  tliis  period,  without  clianye  in  weight,  suggests  tlie  pos- 
sihihty  of  the  utilization  of  this  nitrogen  for  the  repair  of 
tlie  aruemia.     Utilization  of  protein  was  not  disturbed, 

TABLE  LI 
lh«;  r,().     .\ituo(;en  NLctauolism  Hki-okk  and  Te.v  Days  anu  Tiiuee  Munths 

Akieu  Sflenectomy 


Dute 


Vrh. 


IVh, 


I'd 


16 

17 
IS 
19 
20 
21 


Av 
I'e 


.Trage 


b.     2:5 


Mar.  5 

M.ir.  tt 

Mar.  7 

Mar.  8 

MiiT.  !» 

.\Lir.  10 

Mar.  11 


8.5 

.S.."> 
,S,.5 
8.4 
8.4 
8.4 
8.4 


Urine. 


3.43 
3.43 
3.43 

3.43 1 
3.43 
3.43 
3.43  j 


100 
11. J 
140 
120 
120 
200 
'.»0 


10 
39 
44 
38 
42 
47 
30 


Acid 

Acid 
Acid 
Acid 
Acid 
Acid 
Acid 


S^ 


!  -e 


f/m.      gm.      (jm.       urn.    I  ;;m. 

t).30  2.03  0.13'o.2210.014i0.35 
0.00  2.01  0.1 7 0.2700.0221 0.3.5 
(J.13;2.3lt  0.14  0.27<»0.022[0.35 
0.30  2.fi:!  0.17ii>.31!M),0r)7  0.;i,-) 
0.30, 2,7:i  O.li;  0.201  0.1 10  0.3,5 
t).,30i2.0I  0.13  0.20.".O.OS4<0.:i.5 
(i.l.")'2.(iO  0.1  t  0.2,')3 0.007,0.3.") 


8.4  : 3.431  120  i  43 


-L 


.98 
.90 

.74! 
.98  i 

.o,s 

,9t)  i 
•hi  ] 


+0.45 
+0.47 
+0.06 
+0.45 
+  0.35 
+0.47 
+0.48 


_>j^2 r  2 ilO  O.I5O.207I0.O55; 0.35  i  2.95 
Splenectomy 


+0.48 


.\vcranc 


May  20 

May  21 

Mav  22 

May  23 

.MaV  24 


8.0 
8.0 
8.0 
S.O 
7.9 
7.9 
7.9 


3.37  105  I 
3.37!  110' 
3.37  i  150! 
3.37!  210: 
3.37  j  170  1 


3.3; 
3.3; 


8.0    3.3< 


130 
170 


Averui:u. 


7.9  13.78 1  130 
7.9  |3.7sj  115 
7.9  |3.7>;'  130 
7.9  ,3.78 1  200 
7.9  13.78]  115 


47 
46 
44 
40 
42 
49 
38 


Acid 
I  Acid 
.\cid 
.\cid 
Acid 
Acid 
.\cid 


15  3 

15:3 
50 1 3 

.8,5 1 3 

15:3 


11  0. 
00  0. 
.19  0. 
30  0. 
32  0. 
IS  0. 
09  0. 


13:0.2310 
110.2130 
14  0.234  0, 
10  0.2210, 
160.2130. 
10  0.2130. 
12  0.213  0. 


.1210.4113, 
113  0.41]  3. 
0M;0.4i:3. 
119  0.41]  3. 
144  0.41 1 3. 
U!  0.4113. 
129  0.41:3. 


44 


0.1 


.17  0.14 ,0.220,0.12210. 11  i:i.' 


7.9  I3.78i  156 


Acid 
Acid 
Acid 
Acid 
Acid 


1.17 
!.07 
1.24 

;.56; 
:.47 


r 


.30 


0.21.30, 
0.21:  '), 
'0.22.-)  0 
().23S0, 
ii213;o. 


029]  0.38 
0140.38 
010:0.38 
01 7!  0.38 
014!0.3S 


1O.22OO.OI7  0.38 


*  I)if*t:  boilo'J  hfQi  heart,  75  (<m.:  lurd, 

t  ['..xprpsytsi  u^  nogutiM'  luKurUhin:^. 


:.45 
:.02 
:.94 

1.85 


-0,15 
-0.04 
-0.04 
-0.34 
-0.36 
-0.22 
-0.13 


-0.18 


+  L23 
+  1.33 
+  1.16 

+0.84 
+0.93 


40  j^ni.;  «iiKar,  -iU  (cni 


2.08  +1.10 

i 


being  90  per  cent,  in  Period  1,  88  per  cent,  in  Period  II, 
and  ;)()  per  cent,  in  Period  III. 

I^iilike  tlie  other  three  dogs,  we  had  here  in  Period  II 
an  increase  of  creatine  amounting  to  1,5  per  cent.     This 


I 
j 


190 


THE  SPLEEN  AND  AN^MLV. 


increase  was  at  the  expense  of  the  creatinine,  however, 

for  the  total  creatinine,  including  preformed  creatinine  and 

creatine  as  creatinine,  agrees  very  closely,  in  the  two  periods, 

amounting  to  0.314  gm,  in  the  foreperiod  and  0.325  gm.  in 

the  after-period. 

TABLE  LII 
Fat  Detesminations  Lefobe  and  After  Splenectomt 


Dog 

No. 


48 


52 


£6 


67 


Period* 


Total 
intake 


Total     I      Fat 
output    '  utilized 


I 

(7  days) 
Nov.  24 

II 
(7  days) 

III 
(7  days) 

I 
(7  days) 
Dec.     2 

II 
(8  days) 

III 
(7  days) 

IV 
(5  days) 

I 

(7  davs) 
Feb.  "23 

II 
(7  days) 

I 

(7  days) 
Mar.    7 

II 
(7  days) 


gm. 
460.6 


gm. 

26.54 


Splenectomy 
460.6        20.92 

460.6 

374.8 


15.77 
9.19 


Splenectomy 
428.32      12.64 

374.8 

267.7 


298.4 

Splen 
298.4 

380.45 


17.14 

7.85 

13.59 


Splenectomy 
14.25 


23.87 


Splenectomy 
380.45  t    10.56 

i 


per  cent. 

94.2 


95.5 
9^.6 
97.5 

97.0 
95.4 
97.1 

95.4 

95.2 

93.7 

97.2 


Total  out-  I  I 

put  of  fatty  Fatty  add*' 


Bcida  in- 
cluding 
soaps 


io  total 
output 


Total 

output 

neutral 

fata 


Neutral 
fat  in 
total 

output 


gm. 

22.45 


18.11 

11.51 

6.29 

5.93 
8.44 
6.71 

9.27 

11.11 

19.42 

7.68 


■per  cent. 

84.4 


86.5 
73.0 
68.4 

46.9 
49.2 
85.5 

68.3 

78.0 

81.4 

72.7 


0m. 

4.09 


2.81 
4.26 
2.90 

6.71 
8.70 
1.14 

4.32 

.3.14 

5.04 

2.88 


per  cent. 

15.6 


13.5 
27.0 
31.6 

53.1 
50.8 
14.5 

31.7 

22.0 

18.6 

27.3 


•  These  periods  correspond  exactly  to  those  in  Tables  I,  II,  III,  and  IV. 

During  Period  III,  while  the  average  creatine  output 
was  exactly  the  same  as  during  Period  II,  the  creatine  out- 
put fell  to  a  figure  lower  than  either  of  the  preceding 
periods.  The  variation  in  the  partition  of  creatine  and 
creatinine  in  this  animal  we  are  unable  to  explain. 


METABOLISM  STUDIES  ON  THE  DOG 


191 


Fat  Utilization.— The  utilization  of  fat  (Table  LII) 
in  all  the  animals  was  normal  in  all  periods.  The  partition 
of  fatty  acids  (including  soaps)  and  neutral  fats  shows 
some  variation,  especially  in  Dog  52,  hut  to  this  we  are 
inclined  to  ascribe  no  importance.  A  thorough  search  of 
the  literature  shows  that  no  studies  of  fat  utilization  in 
animals  before  and  after  splenectomy  have  previously 
been  made. 

Iron  Metc^oUsm. — As  has  been  shown  elsewhere  (see 
p.  119) ,  Dogs  57, 48,  and  52  showed  no  important  change  in 
the  elimination  of  iron  after  splenectomy,  while  Dog  56  did. 

Discussion 
These  obsen'ations  show  that  in  three  of  four  animals 
the  removal  of  the  spleen  had  no  effect  upon  nitrogen 

TABLE  LIII 

BloUD   ExUflNATIONB 


Dof  No. 

Period* 

Hemodobin 

Red  call  count 

48 

SO 
ST 

I 

u 
m 

I 

II 

m 

IV 

Initial 
I 
II 

m 

i 
II 

per  cent. 

100 
IM 
100 

106 

100 

84 

90 

105 
83 
70 
73 

86 
90 

5,900,000 
5,670,000 
5,540,000 

6,700,000 
6,840,000 
5,360,000 
6,100,000 

6,450,000 
6,020,000 
5,890,000 
4,950,000 

6,130,000 
6,130,000 

*  The  periods  corn 

!spond  exactly  to  those 

of  the  previous  tables. 

metabolism,  the  utilization  of  fat,  or  the  elimination  of 
iron,  and  justines  the  conclusion  that  the  removal  of  the 


192 


THE  SPLEEN  AND  ANiEML\ 


iioniuil  spleen  in  a  normal  animal  has  no  important  effect 
upon  general  metabolism.  It  is  necessary,  however,  in 
order  that  there  may  he  no  question  about  this  conclusion, 
to  explain  the  discordant  results  in  the  fourth  animal 
(Do<>  .')(;).  This  animal  showed  a  loss  of  wei^-ht,  an 
increased  elimination  of  iron  (see  p.  119),  and  a  disturbance 
of  creatine  metabolism.  The  fat  metabolism  was  unaltered. 
The  question  arises  whether  these  chancres  are  due  to  the 
al)sence  of  the  spleen  or  to  the  ana^nia  which  was  present. 
h  Table  I.IU  are  presented  the  blood  examinations  of 
eacli  doy  at  tlie  tiiiie  of  the  several  metabolism  j)eriods. 

It  will  I)e  seen  that  Dons  4,8  and  .IT  showed  no  aj)precia- 
able  ehanuo  in  the  blood  picture  after  splenectomy,  but 
that  I)o,!4s  52  and  .jfj  did.  The  blood  chancres  in  l)o<r  .52, 
b()we\er,  were  relatively  slioht.  The  situation  in  re,<rard  to 
Do.U'  .)()  was  somewhat  different.  This  animal  had  been 
placed  on  a  constant  diet,  the  chief  article  of  which  was 
boiled  beef-heai-t.  twelve  weeks  before  tlie  first  metabolism 
study.  At  that  time  the  blood  examination  showed  JKcmo- 
.U'lobin  lO.j  per  cent,  and  led  cells  0.1.50,000.  At  the  time 
of  our  j)resplenectomy  period  it  showed  a  relatively  low 
liicmonfloljin  content  (88  jjcr  cent.)  a!id  0,020.000  red  cells. 
After  splenectomy  the  haemoglobin  continued  to  fall  until, 
two  and  a  half  months  after  operation,  it  showed  the  hnv 
level  of  ha-moo-loliin  GO  per  cent,  and  red  cells  4...50O.OOO. 
It  is  evident,  therefore,  that  this  animal  diflPered  from 
the  other  three  in  that  it  developed  an  ana-mia  more  rapidly 
and  eventually  of  a  more  severe  /xrade  than  w;is  the  case  in 
any  other  animal  of  this  series.  As  we  have  shown  else- 
whei-e.  anaemia  of  varying  severity  is  a  fairly  constant  result 
of  splenectomy  in  the  do^.  The  anainia  may  be  slight, 
as  in  Dog  .52,  or  more  severe,  as  in  Doo-  .56,  and  may,  as 


I- 


METABOLISM  STI.DIES  ON  THE  DOG 


1»3 


has  been  sug^e.st<(l,  be  lessened  by  diet.  The  influence  of 
diet  we  have  already  discussed,  but  it  is  not  a  matter  which 
concerns  us  at  the  present  time  (see  p.  22).  The  essential 
fact  is  that  Do<>;  56  develoi)ed  a  severe  anaemia,  already 
I)rogressive  at  the  time  of  the  first  metabolism  study,  while 
l)ot?s  48  and  57  were  not  ana-mic,  and  Do^  52  showed  only 
a  slight  non-progressive  deterioration  of  the  blood.  The 
(juestion  naturally  arises:  Is  the  in^-reased  elimination  of 
iron  and  the  disturbance  of  the  creatine  metabolism  due 
to  the  ana?mia  and  not  to  an  influence  on  metabolism  con- 
sequent upon  the  al)sence  of  the  spleen? 

A  few  words  are  necessary  concerning  Richet's  state- 
ment that  the  splenectomized  dog  requires  more  food  to 
maintain  its  weight  than  does  the  normal  dog.  In  view 
of  our  results,  Ilichet's  eonclrsion  is  not  tenable.  Dog  57 
(Table  XLVIII)  maintained  its  presplenectomy  weight 
without  change  in  diet  and  with  only  a  slight  change  in  the 
nitrog-n  balance.  Dog  48  (Table  XLIX)  likewise  showed 
only  a  trifling  change  during  the  three  weeks  after  opera- 
tion and  a  return  to  the  previous  weight  after  seven  to 
eight  weeks.  The  serious  loss  of  weight  in  Dog  52  was 
due  to  loss  of  appetite,  and  that,  relatively  slight,  in  Dog  56 
was  complicated  by  the  coexisting  anaemia. 

Moreover,  during  the  past  five  years  we  have  fre- 
quently noticed  a  tendency  for  splenectomized  dogs  to 
become  obese,  and  this  tendency  is  mentioned  also  by 
several  investigators  who  have  studied  splenectomized  ani- 
mals for  long  periods  of  time.  This  tendency  to  put  on 
weight  is  strikingly  shown  by  two  of  the  dogs  (48  and  52) 
of  this  series.  At  the  close  of  the  metabolism  work,  pre- 
sented in  Tables  XLIX  and  1.,  these  animals  were  not 
destroyed,  on  account  of  the  possible  necessity  of  repeating 

13 


*     Is 


ilH 


I 


'*-,'•      '■' 


i 


194 


THE  SPLEExN  AND  ANEMIA 


^^L'' 


the  metabolism  studies  after  longer  periods  had  elapsed. 
The  change  from  a  special  to  the  ordinary  kennel  d^et 
("table  scraps")  led  to  a  rapid  increase  of  weight  in 
each  instance;  in  tliree  months  the  weight  of  Dog  48  in- 
creased from  13.4  to  1.5.8  kilos.,  while  in  two  months 
Dog  52  rose  from  10.9  to  12.9  kilos. 

Our  results  are  therefore  in  accord  with  those  of  Paton 
rather  than  with  those  of  Kichet,  and  demonstrate  that  in 
the  absence  of  anaemia  the  removal  of  the  spleen  has  no 
influence  upon  nitrogen  or  fat  metabolism,  and  in  all  prob- 
ability no  influence  upon  iron  elimination. 

Our  general  results  may  be  summarized  as  follows : 

Four  dogs  have  been  subjected  to  metabolism  studies 
before  splenectomy  and  at  intervals  of  three  days  to  three 
months  after  splenectomy.  In  three  of  the  four  animals 
the  removal  of  the  spleen  was  not  followed  by  any  dis- 
turbance of  nitrogen  metabolism,  fat  utilization,  or  iron 
elimination.  Two  of  these  animals  showed  no  anaemia,  and 
the  third  only  a  slight  reduction  in  haemoglobin  and  num- 
ber of  red  cells. 

A  fourth  animal,  studied  ten  days  and  three  months 
after  splenectomy,  develo])ed  eventually  a  definitely  pro- 
gressive ansmia  of  moderate  severity.  This  animal  showed 
a  slight  loss  of  weight,  a  slight  disturbance  of  nitrogen 
balance,  and  of  creatine-creatinine  partition,  with  a  marked 
increase  in  the  elimination  of  iron.  We  conclude,  there- 
fore, that,  under  the  conditions  of  our  experiments,  there 
is  no  evidence  that  the  spleen  has  an  influence  on  metab- 
olism, and  we  regard  the  disturbances  occurring  in  one  of 
our  dogs  as  due  to  the  coexisting  anaemia  and  not  to  the 
absence  of  the  spleen. 


; 


CHAPTER  IX 
GENERAL  SUMMARY  OF  EXPERIMENTAL  STUDIES 

After  splenectomy  in  dogs  three  prominent  phe- 
nomena are  observed: 

1.  An  antemia  of  the  secondary  type,  mild  or  moderate 
in  character,  which  usually  rvtaches  its  severest  stage  after 
one  and  a  half  months  and  is  followed  by  repair,  wh,"  ^h  is 
well  advanced  after  three  or  four  months  but  may  not  be 
complete  for  longer  periods  of  time. 

2.  An  increased  resistance  of  the  red  blood-cells  to 
hypotonic  salt  solutions,  hsemolytic  serimi,  saponin  and 
cobra  venom,  and  mechanical  shaking. 

3.  A  lessened  tendency  to  hfemoglobinuria  and  jaun- 
dice, and  sometimes  an  absence  of  jaundice,  after  the  ad- 
ministration of  hemolytic  agents. 

The  ana?mia  may  be  irregular  in  its  onset  and  severity, 
as  may  be  also  the  repair  process,  but  as  a  rule  it  has  a  very 
definite  course.  The  decrease  in  hasmoglobin  content 
occurs  usually  a  little  later  and  is  often  slightly  more 
marked  than  the  decrease  in  red  blood-cells.  The  former 
seldom  falls  below  55  per  cent,  or  the  latter  below  3,000,- 
000.  Neither  during  the  period  of  anaemia  nor  repair  do 
nucleated  or  other  abnormal  types  of  cell  appear  in  the 
peripheral  blood,  except  occasionally,  at  the  time  of  begin- 
ning repair.  The  behavior  of  the  white  cells  is  quite  con- 
stant; shortly  after  operation  a  marked  rise  to  26,000  to 
38,000  occurs,  with  a  return  after  a  few  days  to  20,000 
and  a  gradual  decrease  to  normal  level  after  one  to  four 
months.    The  increase  in  leucocytes  is  almost  entirely  an 

1« 


'  t 


1- 


H 


196 


THE  SPLEEN  AND  .VX.EMIA 


increase  in  the  polyiiiorphomielear  type,  the  lympliocytes 
later  showing  a  sh^rJit  inerease.  The  hehaxior  of  th'j 
eosinophiles  is  inconstant. 

The  "  blood  crisis,"  so  frequently  found  after  removal 
of  the  human  spleen  in  splenic  disease,  is  not  present  after 
the  rem'  val  of  tlie  normal  do^'s  spleen. 

l)i'  ary  studies  indicate  that  the  ana'niia  is  not  influ- 
enced by  the  amount  of  iron  furnished  in  the  food.  On  the 
other  hand,  a  small  number  of  experiments  furnish  some 
evidence  that  the  ana-mia  is  apt  to  l)e  mce  severe  when 
the  animal  is  fed  on  cooked  food  than  when  it  is  fed  on  an 
uncooked  diet.  Control  experiments,  in  which  other  oix?ra- 
tive  procedures,  such  as  unilateral  nephrectomy,  have  pre- 
ceded splenectomy,  prove  conclusively  that  it  is  the  absence 
of  the  spleen,  and  not  post-operative  accidents  or  compli- 
cations, that  is  the  essential  factor  in  the  production  of 
ana?mia. 

A  review  of  the  literature  of  splenectomy  in  man  shows 
that  after  removal  of  the  spleen  for  injury  or  simple  lesion 
not  involving  a  distui-banee  of  the  function  of  the  spleen, 
as  rupture,  twist,  and  cyst,  a  mild  anjemia  of  variable  course 
is  the  rule,  and  that  in  the  absence  of  the  spleen  the  repair 
of  antpmia  is  delayed. 

The  increased  resistance  of  the  red  blood-cells  is  a 
property  of  the  red  cell  itself  and  is  not  due  to  an  anti- 
hsemolytic  power  of  the  serum  or  to  changes  in  comple- 
ment content.  The  exact  reason  of  this  increased  resist- 
ance is  not  evident.  Its  association  with  ansemia  and  the 
concomitant  repair  suggests  that  the  presence  of  young 
and  more  resistant  cells  might  explain  it.  We  have  not 
been  able,  however,  to  demonstrate  an  increase  in  nucleated 
cells  or  in  the  reticulated  cells,  usually  considered  as  vounsr 
forms  indicative  of  active  blood  formation  and  more  resist- 


SOIMARY  OF  EXPERIMENTAL  STUDIES  197 

ant  to  lytic  agents.  We  believe,  however,  that  the  in- 
creased resistance  of  the  rtd  cells  is  not  dependent  merely 
on  the  absence  of  the  spleen,  but  is,  in  part  at  least,  in 
some  way  associated  with  the  anc-emiu,  or  the  factor  or 
factors  causing  it,  thuii  differing,  in  our  view,  from  Banti 
and  his  associates. 

In  regard  to  the  decreased  tendency  to  hjpmoglobin- 
uria  and  jaundice  after  the  administration  of  hiemolytic 
agents,  we  offer  experimental  evidence  to  indicate  that  ( 1 ) 
absence  of  the  spleen  does  not  prevent  the  secretion  of  bile; 
(2)  the  spleen  does  not  influence  the  transformation  of  free 
hfemoglobin  into  bile-pigment,  and  (3)  that  fresh  splenic 
extracts  have  no  demonstrable  action  in  vitro.    Two  im- 
portant factors  appear  to  be  (a)  the  influence  of  anremia, 
and  (b)  the  increased  resistance  of  the  red  cells,  in  that 
each  reduces  the  amount  of  hemoglobin  set  free.    The  most 
important  factor,  and  a  purely  mechanical  one,  concerns 
the  way  in  which  the  ha?mogl()bin  set  free  by  blood  de- 
struction reaches  the  liver.    Under  normal  conditions  the 
disintegrating  biood-cells  accunmlate  in  the  spleen  and  the 
liberated  hfcmoglobin  normally  reaches  the  liver  directly 
and  in  concentrated  form  through  the  portal  vein,  and,  as 
a  result,  hemoglobinuria  and  jaundice  are  more  apt  to 
occur.     In  the  absence  of  the  spleen  it  reaches  the  liver 
through  the  general  circulation    (hepatic  artery)    more 
slowly  and  much  diluted,  and  hemoglobinuria  is  therefore 
less  frequent  and  jaundice  is  of  less  degree  or  entirely 
absent.    Our  experiments  in  which  injections  of  hemoglo- 
bin into  the  mesenteric  vein  were  contrasted  with  injections 
of  hemoglobin  into  the  femoral  vein  offer  conclusive  proof 
of  the  correctness  of  this  view,  as  do  also  experiments  in 
which,  by  means  of  an  Eck  fistula  and  by  anastomosis  of 
the  splenic  vein  with  the  vena  cava,  the  splenic  blood  was 


il 

n 

:  I 


fc 


a 


11 


198 


THE  SPLEEN  AND  ANAEMIA 


diverted  from  the  liver  without  removal  of  the  spleen. 
Another  important  mechanical  factor  connected  with  the 
blood  supply  to  the  liver  is  that  in  splenectomized  animals 
the  total  volume  of  the  portal  blood  supply  is  consider- 
ably lessened.  Further  support  of  this  view  is  found  in 
the  ansemia  that  followed  ligation  of  the  splenic  veins  and 
in  the  single  experiment  where  the  mesenteric  vein  was 
unwittingly  transplanted  into  the  vena  cava. 

Another  factor  which  we  have  discussed  in  this  con- 
nection is  that  concerning  the  influence  of  fatty  acids  as 
brought  forth  by  Joannovics  and  I'ick.  Their  views  are 
supported  by  Eppinger  and  King,  who  find,  after  sple- 
nectomy in  the  dog,  a  decrease  in  the  unsaturated  fatty 
acids  and  an  increase  in  the  cholesterin  content  of  the  blood, 
changes  which  might  well  have  an  influence  on  the  degree 
and  velocity  of  h£emolysis.  Their  observations,  unfortu- 
nately, we  cannot  confirm. 

In  regard  to  the  problem  of  the  ana?mia,  detailed  com- 
parison of  the  arterial  and  venous  blood  of  the  spleen 
offers  no  evidence  to  indicate,  by  the  methods  used,  that  the 
spleen  has  an  important  role  in  blood  formation,  or,  on 
the  other  hand,  that  it  is  appreciably  active  in  blood 
destruction. 

The  injection,  however,  into  normal  dogs  of  fresh 
spleen  extract  Joes  cause  an  evanescent  but  definite  in- 
crease in  lijpmoglobin  and  red-cell  content,  which  is  not 
caused  by  extracts  of  other  organs.  This  result  would 
appear  to  be  brought  about  through  a  stinmlating  action 
on  the  l)one-marrow.  On  the  other  hand,  i"rcsh  beef  spleen 
fed  liberally  to  sjilencotomized  dogs  does  not  prevent  the 
occurrence  of  anivmia. 

If  in  splenectomized  dogs  which  have  recovered  fi-om  the 


SUM]MARY  OF  EXPERIMENTAL  STUDIES 


199 


anaemia  following  removal  of  the  spleen  a  second  anaemia 
is  produced  by  administering  some  haemolytic  agent,  this 
anasmia,  as  shown  by  direct  blood  examination,  runs  a 
longer  course  and  has  a  longer  period  of  repair  than  is  the 
case  in  the  normal  dog.  Here  we  have  an  apparent  para- 
dox, for,  as  has  been  pointed  out  above,  the  red  cells  of 
the  splenectomized  animal  are  more  resistant  to  haemo- 
lytic agents  than  are  those  of  the  normal  dog,  and  theo- 
retically one  would  expect  a  mild  a-  eemia  of  shorter  course 
with  quick  repair. 

Our  explanation  of  the  paradox  is  that  in  the  spleenless 
dog  some  factor  is  at  work,  due  to  the  absence  of  the  spleen, 
which  prevents  rapid  blood  regeneration.  The  normal 
dog,  though  suffering  as  great,  or  even  a  greater,  blood 
destruction,  has  no  fault  in  regeneration,  and  its  blood  re- 
turns quickly  to  normal.  On  the  other  hand,  in  the  splenec- 
tomized dog  the  factor  delaying  regeneration  operates 
after  an  acute  anamia,  as  it  did  originally  after  removal 
of  the  spleen,  and  therefore  the  anaemia  often  reaches  a 
lower  level  and  is  repaired  more  slowly. 

Experiments  undertaken  to  show  that  this  unknown 
factor  might  be  a  function  of  the  spleen  concerned  in  the 
utilization  of  iron  for  the  marmfacture  of  hfemoglobin 
have  given  negative  results.  Occasionally,  shortly  after 
splenectomy,  a  slight  increase  in  elimination  of  iron  was 
observed,  but  we  have  found  no  evidence  of  disturbance 
of  iron  metabolism  one,  nine,  and  twenty  months  after 
splenectomy.  The  most  marked  disturbance  of  iron  meta- 
bolism occurred  in  a  dog  with  a  moderately  severe  anemia, 
and  we  believe  that  an  increased  elimination  of  iron  is  a 
manifestation  of  increaseti  blood  destruction  and  not  di- 
rectly dependent  on  the  absence  of  the  spleen. 


«00 


THE  SPLEEN  AND  ANJCML\ 


Control  studies,  in  wliich  without  removal  of  the  spleen 
the  spk'iic  blood  was  diverted  from  tlie  liver  by  means 
of  an  Lck  fistula  or  an  anastomosis  of  the  splenic  vein 
with  the  vena  cava  or  ligation  of  the  splenic  vein,  yielded 
results  similar  to  those  following?  splenectomy,  but  varj-ing 
somewhat  in  def^ree  or  duratioii.  The  ana?mia  and  the 
icterus,  as  also  the  slow  repair  of  anjcmia,  under  these 
circumstances  did  not  differ  greatly  from  the  results 
following  splenectomy.  If  the  auivmia  is  due  to  the  loss 
of  a  stimulating  action  on  the  bone-marrow,  these  experi- 
ments show  that  access  to  the  liver  is  necessarj'  for  the 
activation  of  such  stimulant.  The  increased  resistance 
of  the  red  cells,  on  the  other  hand,  did  r-  t  persist  for  so 
long  a  time  as  after  splenectomy.  The  lessened  tendency 
to  jaundice,  on  account  of  the  important  mechanical  factor 
involved,  was  quite  similar  to  that  following  splenectomy. 
These  observations  emphasize  the  importance  of  the 
mechanical  factor  (the  disturbance  of  the  direct  blood  flow 
to  the  liver),  and  suggest,  also,  some  functional  relation  of 
the  spleen  to  the  liver  that  is  not  yet  fully  understood. 

Studies  of  the  l)one-marrow  after  splenectomy  show 
that,  as  a  rule,  tlic  fatty  marrow  of  the  long  bone  is  trans- 
formed into  red  marrow.  During  the  early  months  this 
change  is  slight  or  absent,  but  after  six  to  twenty  months 
it  is  fairly  constant  and  complete.  There  is  no  evidence 
that  this  change  is  compensatory  to  the  early  antemia 
caused  by  splenectomy  or  to  an  increased  hannolysis  in  the 
lymph  nodes.  It  may  I)e  that  it  is  a  concomitant  of  the 
activity  of  the  bone-marrow  in  taking  over,  in  the  absence 
of  the  spleen,  the  function  of  storing  aiul  elaborating  th(> 
iron  of  old  blood-pigment,  but  our  observations  do  not  fully 
support  tliis  liypothesis. 


SUM>L\RY  OF  EXPERIMENT.VL  STUDIES 


201 


The  lymph-nodes,  after  splenectomy,  exhibit,  as  a  rule, 
a  great  increase  in  the  number  of  endothelial  cells.  In 
most  splenectomized  dogs  that  succumb  to  a  haMiiolytic 
agent  within  forty-eight  hours  the  sinuses  of  the  lymph- 
nodes  contain  large  r.^mbers  of  endothelial  cells  filled  with 
red  blood-corpuscles.  This  is  seen,  also,  to  a  less  extent 
in  the  case  of  the  stellate  cells  of  the  liver  capillaries.  This 
phenomenon  has  not  been  seen  to  the  same  extent  in  normal 
dogs  receiving  hjcmolytic  serum.  Such  findings  suggest 
that  in  the  absence  of  the  spleen  the  function  of  forn?ing 
red-blood-cell-phagocv-tic  cells— normally  a  minor  func- 
tion of  the  lymph-nodes— becomes  highly  developed  in 
these  structures  and  is  shared  also  by  the  liver,  and  that 
in  times  of  stress,  as  after  excessive  blood  destruction, 
these  organs  assume,  in  part  at  least,  the  function  of 
destroying  red  blood-cells  by  phagocytosis.  The  small 
iron  content  of  the  lymph-nodes  and  liver  indicates,  how- 
ever, that  under  noi,nal  circumstances,  in  the  splenecto- 
mized animal,  no  excessive  destioiction  of  this  type  occurs. 

Detailed  metabolic  studies  have  demonstrated  conclu- 
sively that  the  removal  of  the  normal  spleen  in  a  noi-mal 
animal  has  no  effect  on  nitrogen,  fat,  or  iron  metabolism. 
^Vhen  disturbance  of  nitrogen  and  iron  metabolism  occurs 
it  is  due,  in  all  i)robability,  to  a  coexistent  antcmia,  and 
not  to  the  mere  absence  of  the  spleen. 

In  conclusion,  we  wish  to  state  frankly  that,  while  the 
experiiiients  here  described  add  to  our  knowledge  of  cer- 
tain i)hases  of  the  relation  of  the  spleen  to  blood  destruc- 
tion and  regeneration,  we  fire  still  in  doubt  about  the  exact 
cause  of  (a)  the  ana?mia  and  (h)  the  increased  resistance 
of  the  red  cells  which  so  constantly  follows  splenectomy. 


CHAPTER  X 

METABOLISM  STUDIES  ON  MAN  BEFORE  AND  .UiTER 
SPLENECTOMY 

Studies  of  metabolism  after  splenectomy  in  the  normal 
dog,  as  has  been  shown  in  the  preceding  chapter,  are  es- 
sentially negative.  In  man  the  situation  is  entirely  differ- 
ent. Splenectomy,  for  chronic  disease  at  least,  is  done  in 
the  presence  of  an  anasmia  of  more  or  less  jeverty,  and 
the  alterations  in  metabolism  before  operation  are  largely 
those  dependent  on  the  changes  in  the  blood.  The  im- 
provement following  splenectomy  is  to  be  regarded,  there- 
fore, not  as  dependent  on  the  removal  of  a  normal  fvmction 
of  the  spleen,  but  as  dept  t  on  the  removal  of  a  ha?mo- 

lytic  or  other  toxic  activil  j/  vhich  the  altered  physiology 
of  the  spleen  is  responsible.  Metabolism  studies  in  man, 
under  such  conditions,  thus  become  valuable  adjuvants 
to  the  blood  examination  in  determining  the  type  of  splenic 
disease  or  anjemia  in  Avhich  favorable  results  from  splenec- 
tomy may  be  expected. 

As  investigations  of  this  type  are  comparatively  new — 
to  our  knowledge  only  five  studies  of  conditions  l)oth  before 
and  after  splenectomy  have  been  made — we  present  in  con- 
siderable detail  two  carried  out  under  our  direction:  one 
in  cotmection  with  congenital  ha?molytic  jaundice""  and 
the  other  in  connection  with  pernicious  ana^mia.^" 

Tx  CoxGEXiTAi,  Hemolytic  Jaitxdice 
The  subject  of  the  first  of  these  was  a  child  suffering 
from  congenital  ha^molytic  jaundice  presenting  the  fol- 
lowing history: 

202 


'if 


METABOLISM  STUDIES  ON  MAN 


am 


At  birth,  at  term,  the  child  weighed  seven  pounds,  and 
is  described  as  lacking  the  characteristic  red  color  of  the 
newly  bom.  About  twenty-four  hours  after  birth  the 
"  alabaster  whiteness  "  of  the  skin,  which  the  mother  de- 
scribed, changed  to  a  mahogany  brown,  which  lasted  three 
months,  gradually  fading  to  a  sallow  pallor,  which  has 
persisted.  xVt  six  months,  when  the  child  passed  through 
an  attack  of  pneumonia,  it  weighed  only  ten  pounds.  The 
general  health  was  poor  and  gastro-intestinal  disturbances 
frequent.  In  the  fourteenth  month  the  first  severe  anaemia, 
accompanied  by  dark-brown  discolorations  of  the  skin  and 
preceded  by  protracted  vomiting  and  diarrhoea,  was  ob- 
served. Two  months  later  a  similar  attack  occurred,  with 
the  new  feature  of  marked  oedema  of  the  entire  body. 
During  these  attacks  the  rectal  temperature  usually  rose 
to  104  or  105.  Periods  of  recrudescence  and  exacerbation 
followed  one  another  imtil  the  child  was  two  and  one-half 
years  old,  when  an  unusually  severe  attack  kept  him  in 
bed  for  five  months.  Vomiting  and  diarrhoea  were  severe, 
and  hemorrhages  from  the  nose  and  bowel  were  frequent 
and  difficult  to  control.  During  the  second  month  of  this 
period  a  partial  paralysis  of  the  left  side  developed.  At 
this  time  an  injection  of  neosalvarsan  was  given,  more  for 
the  hsematinic  action  of  the  arsenic  than  with  any  suspicion 
of  lues.  Gradual  improvement  followed  this  treatment, 
and  after  the  paralysis  had  disappeared,  except  for  a  resid- 
ual spastic  palsy  of  the  left  leg,  tlie  child  enjoyed  fairly 
good  health.  The  Wassermann  reaction,  frequently  re- 
peated, has  always  been  negative.  During  the  eight 
months  following  this  attack  salvarsan  was  given  five  times 
by  rectum.  About  the  time  he  was  five  yerrs  old,  and 
again  seven  months  later,  he  lost  the  power  of  speech,  was 


ti 


f04 


THE  SPLEEN  AND  .»u\^ML\ 


more  or  less  delirious,  and  eomplainedof  pain  in  his  head. 
At  three  and  one-half  and  again,  at  four  and  one-half  years 
he  had  an  otitis  media.  His  appetite  has  always  heen  poor, 
never  normal,  and  at  times  he  refuses  to  eat.  A  tendency 
to  localized  oedema,  especially  of  the  face  and  of  the  hancj, 
has  been  constantly  noted.  He  tires  easily,  and  frequently 
complains  of  this.  Obstinate  constipation  has  heen  the 
rule,  and  the  fa?ces  are  described  as  dark  or  orange  in  color. 
From  the  family  history  it  is  found  that  a  sister  was 
jaundiced  for  ten  days  and  a  brother  for  two  days  after 
birth,  but  these  children,  now  fifteen  and  thirteen  years 
of  age  respectively,  have  otherwise  been  in  good  health. 
The  father  is  said  to  have  had  an  enlarged  spleen  and 
offers  a  histor\'  of  exposure  to  lues,  of  skin  eruption,  and 
chronic  abscess  of  joint  and  ankle.  The  mother,  three 
months  before  the  birth  of  the  subject  of  the  present  studv, 
was  paralyzed  and  suffered  a  separation  of  the  pelvic 
bones.    The  deliver}'  was  under  anfpsthesia. 

Lahoratarji  Eoraminatiom. — An  examination  of  the 
numerous  clinical  records  which  have  accumulated  shows 
that  the  urine  offers  nothing  of  uimsual  interest.  The  only 
positive  finding  is  an  occasionally  slight  trace  of  albumiri. 
Tests  foi-  bile  have  always  been  negative,  and  urobilin 
tests  have  showTi  no  increase  of  this  substance.  Examina- 
tions of  the  f.Tces  indicate  that  food  is  well  digested:  tests 
for  occult  blood  have  been  negative,  and  no  parasites  or 
ova  have  heen  fomid.  Xo  records  of  the  early  l)lood  exam- 
inations have  been  preserved,  except  a  brief  record  that  at 
the  time  of  the  first  severe  attack  (when  fourteen  months 
old)  the  h.Tmoglobin  fell  to  24  per  cent,  and  a  diagnosis  of 
pernicious  an<Tmia  was  made.  A  number  of  counts  made 
during  the  years  1913  and  1914  showed  considera})le  varia- 


METABOLISM  STUDIES  ON  MAN 


205 


tion  in  both  ha^nio^lohin  (from  65  per  cent,  to  28  per  cent.) 
and  red  blood-cells  (4,180,000  to  1,360,000).  The  Brule 
test  and  tests  for  cross  luemolysis  with  normal  serum  and 
cells  were  negative.  The  subsequent  blood  coimts  are  sum- 
marized in  Table  LIV. 

At  the  be^inniii^  (December  3,  1914)  of  our  metab- 
olism studies  a  complete  examination  of  the  child  was  made, 
and  from  the  notes  at  that  time  the  following  abstract  of 
positive  findings  has  Iwen  prepared: 

The  boy  is  five  and  one-half  years  of  age,  105..5  cm.  in 
height,  weighs  39  pounds,  is  well  nourished  and  of  good 
nmscular  development.  His  skin  is  slightly  sallow,  but 
there  is  nc  true  jaundice.  Over  the  vessels  of  the  neck 
a  systolic  bruit  is  heard,  and  an  occasional  slight  systolic 
whifF  is  heard  at  the  apex  of  the  heart.  At  the  base  of  the 
heart  the  first  sound  is  replaced  by  a  systolic  murmur  of 
a  blowing  character,  and  the  second  sounds  are  accent- 
uated. Normal  sounds  are  heard  at  the  tricuspid  area. 
The  liver  is  doubtfully  palpable.  The  splenic  dulness  be- 
gins in  the  mid-axillary  line  at  the  sixth  rib  and  extends 
down  a  little  below  the  line  of  the  umbilicus;  its  greatest 
length  is  18  cm.  and  its  greatest  width  about  9  en).  The 
spleen  feels  firm,  smooth,  and  without  distinct  notches. 
The  right  lower  extremity  is  normal;  the  left  lower  ex- 
tremity normal  as  to  thigh  and  leg,  but  the  ankle  and  foot 
show  a  spastic  paralysis. 

The  urine  at  tliis  time  was  amber  in  color,  with  no 
gross  sedimei  t;  the  specific  gravity  was  1.029;  tests  for 
albumin,  sugar,  acetone,  diacetic  acid,  indican,  and  bili- 
rubin were  negative.  The  test  for  urobilin  gave  a  doubtful 
reaction;  under  the  microscope  some  mucus  was  seen,  but 
no  cells,  casts,  or  crvstals.     The  blood  count  at  this  time 


I    • 


206 


THE  SPLEEN  AND  ANiEMU 


-♦M 

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OiO 

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* 

nc4 

♦  M 

sg 

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* 

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METABOLISM  STUDIES  ON  MAN 


807 


is  given  in  Table  LI  V,  under  the  date  of  December  3, 1914. 

The  first  metabolic  period  ran  from  the  4th  to  the  llth 
of  December,  and  during  this  time  there  was  little  or  no 
change  in  the  patient's  condition.  Throughout  the  period 
there  was  a  tendency  to  elevation  of  temperature,  which, 
however,  rose  but  once  over  101.  The  child  was  not  kept 
in  bed,  ate  regularly,  and  required  no  medication  or  cathar- 
tic. At  the  end  of  the  period  he  was  discharged,  to  return 
after  Christmas. 

During  the  interval  at  home  (December  14,  1914,  to 
'January  2o,  1915)  no  noteworthy  change  in  condition  oc- 
curred. On  January  26  the  patient  was  readmitted  to  the 
University  Hospital,  service  of  Dr.  Charles  H.  Frazier. 
Physical  examination  revealed  nothing  new;  examination 
of  the  blood  and  urine  showed  but  little  change.  On  Jan- 
uary 28  the  spleen  was  removed  by  Dr.  Frazier,  under 
ether  ansesthesia.  The  operation  was  uneventful  and  there 
was  only  a  trifling  loss  of  blood.  At  the  time  of  the  opera- 
tion the  coagulation  time  of  the  blood  was  found  to  be 
about  four  minutes,  and  tests  for  resistance  of  red  cells 
showed  beginning  of  hemolysis  in  0.65  per  cent,  and  com- 
plete hemolysis  in  0.425  per  cent,  salt  solution.  Conva- 
lescen«?e  after  the  operation  was  satisfactory,  and  on  Feb- 
ruary 4  the  patient  was  transferred  to  the  medical  ser\'ice, 
and  the  second  period  of  metabolism  study  was  started  on 
February  5.    At  this  time  the  child's  weight  was  40  pounds. 

On  the  fourth  day  of  metabolism  study  an  attack  of 
bronchiiis  caused  a  rise  of  temperature  to  103,  and  for  two 
or  ;^ree  days  there  was  some  loss  of  appetite,  and  on  the 
ninth  day  a  mild  otitis  media  developed.  Despite  these 
disturbances,  the  metabolism  study  was  continued  until  the 
period  of  ten  days  representing  the  eighth  to  eighteenth 
days  after  splenectomy  was  completed. 


.1 


11 


408 


THE  SPLEEN  ASD  AN\\.EMIA 


W^.: 


At  the  end  of  the  period  the  ehild's  weight  was  38j/l> 
pounds  and  he  seemed  eonsiderahly  improved  in  eolcjr  and 
strength.  The  appetite  was  ^ihh\.  The  eondition  of  the 
bowels  demanded  an  oeeasionai  eathartie,  whieh,  however, 
never  eaiised  watery  stools.  Kven  before  dischartre  on 
February  18,  just  three  weeks  after  operation,  it  was  evi- 
dent tliat  a  marked  improvement  in  the  blood  pieture  had 
oeeurred,  both  hiemo^dobin  and  red  blood-cell  count  being 
double  that  obtained  on  the  first  admission. 

After  discharge  the  improvement  continued  steadily, 
with  greatly  increased  appetite  and  strength.  The  skin 
lost  its  sallow  hue  and  became  normal  in  appearance.  In 
the  two  months  since  operation  the  child  has  enjoyed 
uninterrupted  good  health,  except  for  one  attack  of  indi- 
gestion, the  result  of  overfeeding.  Two  weeks  previous 
to  the  last  blood  count  given  in  the  table  a  rather  severe 
nasal  hemorrhage  occurred  as  a  result  of  excoriations.  The 
lowered  hipmoglobin  in  the  last  count  is  probably  to  be 
explained  by  this  hemorrhage. 

Pathologic  Dksihiption  of  the  Spleen. — The 
weight  is  640  gm.;  length,  18.3  cm.;  width,  10.8  cm.;  thick- 
ness, 3.8  at  one  end,  increasing  to  8.t  at  opposite  end.  The 
organ  is  of  uniform  bluish-red  color.  The  capsule  is  for 
the  most  part  smooth,  with  a  few  fine  adhesions  at  one 
pole,  where  there  is  also  a  small  circumscribed  area  (1.5 
cm.  in  diameter)  of  thickening.  The  vessels  of  the  hilum 
are  normal.    Xo  supernumerary  spleens  are  seen. 

On  section  a  large  amount  of  dark  fluid  blood  escapes. 
The  cut  surface  has  a  uui'  rm  smooth,  glistening  appear- 
ance of  dull-red  color.  The  Malpighian  bodies  are  dis- 
tinctly visible,  but  not  so  large  as  in  the  normal  spleen. 
The  trabeculfB  are  not  prominent.     The  consistence  is 


METABOLISM  STUDIES  ON  MAN 


209 


increased,  it  being  almost  impossible  to  rupture  the  spleen 
by  pressuie  with  the  thumb.  At  one  end  (the  larger) 
of  the  organ  is  a  distinctly  circumscribed,  but  not  encap- 
sulated, mass  (3.5  cm.  in  diameter),  spherical  in  shape, 
which  shows  no  Malpighian  bodies,  but  does  present  a  few 
minute  ochre-colored  areas.  This  area  is  of  the  same 
color  and  consistence  as  the  rest  of  the  spleen.  On  section 
it  bulges  prominently  above  the  cut  surface.  Tlie  weight 
of  the  spleen  after  escape  of  fluid  blood  from  three  longi- 
tudinal incisions  is  435  gm. 

Gross  Diagnosis. — Splenomegaly  with  area  of  recent 
infarction. 

Microscopic  Appearance.— Very  slight  thickening  of 
capsule  with  no  increase  of  trabecula;.  The  sinuses  are 
dilated  and  congested.  The  reticulum  is  increased  in 
amount,  and  the  cells  of  pulp  appear  to  he  decreased  in 
number.  The  Malpighian  bodies  show  no  change  except  a 
hyaline  thickening  of  central  arteries  wliich  is  evident  in 
arteries  elsewhere.  ^Macrophages  are  not  numerous  and 
deposition  of  pigment  is  not  seen. 

The  tumor-like  mass  described  in  notes  on  gross  ap- 
pearance shows  intense  congestion  and  hemorrhage  without 
evidence  of  cell  flestruction,  and  represents,  in  all  proba- 
bility, the  results  of  occlusion  of  blood-vesesls  at  time  of 
operation. 

Histologic  Diagnosis. — Congestion,  increase  of  reti- 
culum, hyaline  degeneration  of  arteries.  ( The  rather  nega- 
tive histologic  appearance  is  in  general  that  described  for 
splenomegaly  with  congenital  h?emolytic  jaundice.) 

Methods  of  Metabolism  Study. — The  child  was  kept 
in  a  private  room  of  the  University  Hospital,  with  a  special 
metabolism  nurse  in  attendance.     The  complete  metab- 

14 


210 


THE  SPLEEN  AND  ANEMIA 


olisiii  study  occupied  one  period  ol  ten  days  luid  a  supple- 
nientaiy  period  of  five  days  betore  splenectomy,  and  a 
period  of  ten  days  after  splenectomy.  The  first  period 
extended  from  December  3  to  December  14,  after  which 
the  child  went  home  for  the  Christmas  holidays.  While 
the  child  was  at  home  a  supplementary  period  of  five  days 
for  the  study  of  uric  acid  elimination  extended  from  Janu- 
ary 20  to  Januarj'  24.  The  return  to  the  hospital  was 
delayed  on  account  of  the  desire  of  the  attendant  phy- 
sicians to  improve,  if  possible,  the  blood  picture  and  the 
general  condition.  On  January  28,  two  days  after  re- 
admission,  the  spleen  was  removed,  and  on  Februarj'  5, 
after  a  lapse  of  eight  days,  the  post-splenectomy  metab- 
olism studies  were  begun  ^'1  continued  for  ten  days.  On 
account  of  the  capricious  u^ypetite  of  the  child,  it  was  im- 
possible to  adhere  to  a  constant  dietary,  such  as  the  Folin 
diet,  and  therefore  considerable  liberty  was  allowed.  The 
intake  was  determined  by  weighing  all  foods  taken  and 
analyzing  portions  for  nitrogen  and  fat  This  policy  was 
followed  in  both  of  the  ten-day  periods,  but  not  in  the 
supple;. It  I  ry  fivc-d.:y  period  when  the  child  was  at  home. 
Despite  the  freedom  as  to  diet,  the  food  intake  was  quite 
constant  in  character  from  day  to  day,  consisting,  in  the 
first  period,  essentially  of  milk,  eggs,  cereals,  apple  sauce, 
bread,  crackers,  potatoes,  butter,  sugar,  rice,  and  tapioca. 
During  the  first  five  days  of  this  period  beef,  chicken,  or 
fish  was  allowed  once  a  day;  during  the  second  five  days 
these  were  entirely  eliminated,  as  they  were  also  in  the 
supplementary  period  of  five  days  before  splenectomy  and 
the  ten-day  period  after  splenectomy.  Thus,  except  in  the 
first  five-day  period,  the  child  was  on  a  practically  purin- 
and  creatin-free  diet.    The  calorific  value  of  the  diet  was 


METABOLISM  STUDIES  ON  MAN 


ill 


adequate.  During  Periods  1  and  II  (Table  LV)  the  sub- 
ject received  approximately  1100  calories  a  day,  or  about 
GO  calories  per  kilo,  of  body  weight.  During  PeritxJs  IV^ 
and  V  the  patient  was  on  a  slightly  lower  calorific  intake, 
but  entirely  adequate;  namely,  960  C!' lories  per  day,  or 
about  jO  calories  per  kilo,  of  body  weight. 

The  nitrogen  of  tiie  food  was  estimated  by  the  Kjeldahl- 
Gunning  method  and  the  fat  by  Soxhl'^t  extraction.  The 
urine  was  collected  in  twenty-four-hour  periods,  and  por- 
tions passed  during  that  period  were  preser\'ed  under 
toluene  in  an  ice-chest.  The  urine  was  acid  to  litnms  at 
all  times. 

In  the  analysis  of  the  urine  the  total  nitrogen  was  de- 
termined by  the  Kjeldahl-Gunning  method;  ammonia  by 
Folin's  '-■'*  method;  urea  by  Benedict's  *'*  method;  uric  acid 
by  Folin's  colorimetric  method;'^''  creatin  and  creatinin  by 
Folin's  method;  '"'  and  the  hydrogen  ion  concentration 
according  to  Henderson's  technique.^" 

In  the  study  of  the  fteces  the  fat  content  was  deter- 
mined by  the  Folin-Wentworth  method;'^-  the  iron  was 
estimated  by  Neumann's  method;'''^  nitrogen  by  the  Kjel- 
liani-Gunning  method,  and  urobilin  by  a  slight  modifica- 
tion of  the  method  recommended  by  Wilbur  and  Addis.*'"* 

Period  III  (Table  LV)  was  considered  a  desirable 
control  on  account  of  the  high  figures  for  uric  acid  obtained 
in  the  first  and  second  periods.  The  analyses  in  this  period 
were  therefore  limited  to  those  determinations  of  special 
interest  in  this  connection. 

Results  of  Metabolism  Study. — In  Table  LV  are 
presented  the  results  of  the  study  of  nitrogen  metabolism. 

Nitrngen  Metaholism. — During  Periwls  T  and  11,  be- 
fore splenectomy,  the  subject  showed  a  slightly  plus  nitre- 


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THE  SPLEEN  AND  ANAEMIA 


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MET.VBOLISM  SlUDLES  ON  MAN 


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THE  SPLEEN  AND  AN.EMIA 


geii  balance.  iVt'ter  splenectoiny,  (iui-in<^-  Period  IV,  a 
^reat  retention  of  iiitrofren  oeeurred,  altliou<rli  tlie  itake 
varied  but  little  from  the  previous  periods  and  the  sub- 
ject was  not  ^ainin^  in  wei^ut.  The  logical  explanation 
of  this  change  would  be  either  of  the  following:  (1)  Re- 
parative processes  going  on  in  the  body,  as  indicated  by 
the  rapid  regeneration  of  the  ha'nioglobin  and  red  cells,  or 
( 2 ;  the  removal  of  toxic  influences,  leading  to  an  improve- 
ment in  the  general  nutritive  condition  and  thus  to  the 
normal  nitrogen  retention  in  a  healthy  child.  The  utili- 
zation of  protein  was  good  at  all  times.  The  average 
percentage  of  total  nitrogen  eliminated  as  urea  was  85.5 
before  splenectomy  and  87.2  afterwards,  figures  within  the 
normal  range.  The  differences  of  the  averages  may  pos- 
sibly be  explained  !)y  the  changes  in  one  of  the  other  nitro- 
gen constituents  of  the  urine;  namely,  uric  acid. 

Uric  Acid. — The  m-ic  acid  output  was  exceedingly 
high  in  PericxJs  I  and  II.  Period  I  was  not  purin-free. 
Period  II,  however,  was  practically  free  from  purin  intake, 
notwithstanding  which  the  uric  acid  output  continued  on 
its  high  level.  The  urines  were  highly  colored,  and  when 
allowed  to  stand  gave  a  precipitate  of  uric-acid  crj'stals. 
In  view  of  this  high  elimination  of  uric  acid  a  supple- 
mentary study  was  made  (Period  III),  during  which  the 
subject  wj's  again  placed  on  a  purin-free  dietary,  consist- 
ing maiidy  of  milk,  eggs,  shredded  wheat,  and  custard. 
In  this  period  the  high  output  of  uric  acid,  presumably 
almost  entirely  endogenous,  still  [>ersisted.  This  average 
(Periods  II  and  III),  0..),30  gm.  of  uric  acid,  is  very  close 
to  the  highest  average  of  uric-acid  output  of  an  adult  on 
a  purin-freo  diet.  Few  figures  for  normal  uric-acid  out- 
put in  children  are  to  be  found  in  the  literature.  Closson,*" 


METABOLISM  STUDIES  ON  ^LVX 


215 


ill  a  cliiUl  of  about  seven  years  of  a^^e,  found  an  average 
output  of  0.23  gni.  on  a  purin-free  diet. 

After  splenectomy  the  average  output  of  uric  acid  in 
Periods  IV  and  V  decreased  47  per  cent,  from  the  average 
of  Periods  11  and  111  before  splenectomy.  It  will  be  re- 
membered that  the  diets  of  all  these  periods  were  purin- 
free.  The  appearance  of  the  urine  in  these  later  periods 
was  markedly  altered,  the  dark-red  color  being  replaced 
by  a  pale  yellow,  with  never  a  spontaneous  precipitate  of 

uric  acid. 

Hydrogen  Ion  Concentration.— On  the  same  general 
diet  the  hydrogen  ion  concentration  of  the  urine  remained 
constant  befor(i  and  after  splenectomy.  During  Period  I. 
on  a  mixed  diet,  an  average  of  .5.87  falls  within  the  normal 
average  (5.94)  of  Henderson  and  Palmer.*'"  On  the 
purin-free  diet  yielding  a  more  alkaline  ash,  the  hydrogen 
concentration  before  operation  is  in  agreement  with  that 
after  the  operation.  It  is  of  interest  here  to  note  that 
the  hydrogen  ion  concentration  is  not  appreciably  altered 
by  changes  in  uric-acid  content  of  urine,  although,  as 
shown  by  Blatherwick,*"  the  ability  of  urine  to  dissolve 
uric  acid'  is  a  function  of  the  hydrogen  ion  concentration. 

Ammonia  Nitrogen.— The  ammonia  nitrogen  in  our 
experiments  shows  no  variations  from  the  normal.  Its 
close  agreement  with  hydrogen  ion  concentration  may  be 
noted;  thus  a  rise  in  the  hydrogen  ion  concentration  is  asso- 
ciated with  a  fall  in  the  ammonia  output,  and  vice  versa. 

Creaiinin  and  Creatin.— The  creatinin  output  showed 
a  great  constancy  in  Periods  H  and  III,  before  splenec- 
tomy, on  the  purin-free  diet.  During  Period  I,  on  a  mixed 
diet]  the  output  is  slightly  above  these  periods.  During 
Period  IV,  after  the  operation,  the  creatinin  output  fell 


I 


I 

I   i 

M 

.  t 

'I 


216 


THE  SPLEEN  AND  i^N^MIA 


to  its  lowest  lit,  a  decrease  of  25  per  cent.  fr.  in  the 
average  of  .>t}ier  purin-free  periods.  Wlien  the  total 
creatinin  (tliat  is,  preformed  creatiiiin  and  creatin  con- 
sidered as  creatinin)  output  of  each  period  is  compared, 
one  readily  sees  that  the  total  creatinin,  in  all  of  th  .■  periods 
on  creatin-free  diet,  shows  a  remarkable  constancy.  As 
will  be  seen  from  an  inspection  of  the  two  tables,  the  de- 
crease of  creatinin  was  accompanied  by  an  increase  of  the 
creatin  amounting  to  91  per  cent,  of  the  average.  Why, 
in  Period  IV,  the  partition  of  creatinin  and  creatin 
changed  without  an  appreciable  change  of  total  creatinin 
is  difficult  to  state.  During  the  last  two  days  of  this 
period  the  patient  suffered  from  a  bronchitis  with  a  rise 
in  temperature,  but  that  these  are  explanatory  factors 
hardly  seems  plausible. 

As  regards  creatin  output,  with  the  exception  of  the 
first  period,  which  was  not  that  of  a  creatin-free  diet,  the 
outjjut  shows  a  fair  degree  of  regularity.  The  increased 
output  in  Period  IV  has  already  been  pointed  out. 

There  is  a  paucity  of  data  on  the  creatinin  and  creatin 
outi)ut  of  children  on  controlled  diets.  The  results  ob- 
tained by  Folin  '-•'  on  his  children  offer  figures  which  may 
serve  for  comparison. 

The  great  constancy  of  our  total  creatinin  (including 
preformed  creatinin  and  creatin  as  creatinin)  output  leads 
us  to  believe  that  for  the  purpose  of  comparison  in  chil- 
dren this  is  the  figure  to  be  used  rather  than  the  relative 
or  absolute  amounts  of  creatin  or  creatinin.  If  we  are 
correct  in  this  view,  the  total  creatinin  output  afrrees  verv 
well  with  other  published  figiires  for  children,  and  we 
therefore  believe  our  creatin  nnd  creatinin  figures  to  be 
witliin  the  range  of  normal  variations. 


METABOLISM  STUDIES  ON  ALiN 


417 


}\ts.— The  total  "ntake  of  fats  and  the  separation  of 
fats  in  the  fa'ces  are  shown  in  Table  LVI.  In  this  table 
Periods  I  and  II  represent  the  pre-splenectomy  and 
Periods  IV  and  V  the  post-splenectomy  studies.  Each 
period  represents  five  days. 

TABLE  LVI 

Fat  Determinations  in  a  Case  of  Congenital  H^molitic  Jaundice  Before 

AND  After  Splenectomv 


Fuiod 


Hpfore  Splenectomy 

1 

II 

After  Spleneutomv: 

IV 

V 


Total 

Total 

intake. 

output, 

gm. 

gm. 

222 

8.88 

223 

7.57 

227 

13.56 

269 

13.55 

Pnr 

reut. 

ul  fat 

utilised 


Total 

output 

fatty 

acids 

including 

Buaps, 

gm. 


96.01    I 
96.62    ' 

94.(H 
94.98 


6.8 
5.1 

!0.1 
9.8 


Per  I 
rent,  1 
fiitly  ! 
ariila  1 
in  total  I 
fut  I 
output 


Total 

output 

ncutrnl 

fata 


Per 

cent. 

neutral 

fata  in 

total 

fai 

output 


76.8 
67.0 


2.1 

2.5 


74.4     I     3.5 
72,3    I     3.7 


23.2 
33.0 

25.6 
27.7 


The  metabolism  of  fats  shows  no  abnormal  variations. 
The  fat  utilization  is  good,  and  well  within  normal  limits. 
As  pointed  out  by  Folin  and  Wentworth,'-'"  as  total  hi 
increases  more  of  that  fat  is  put  out  as  fatty  acids  ( includ- 
ing soaps). 

Iron. Table  LVIl  presents  the  results  of  the  exam- 

TABLE  LVII 

Iron  EiiMiNxnoN  in  Vmckh  in  a  Case  of  Conoenttal  H.f:Moi.i-Tir  .FArxDiCE 
Ukfore  and  After  Splenectomy 


Peiiod 

Total  intake 

period,  nig. 
(calculated) 

Total  output 

period, 

nig. 

Intake 

per  d:i>', 

Mli. 

Output 
per  day, 

Ulg. 

Before  Splenectomy 

37.69 

S2.'.)9 

3.77 

8.29 

11 





...       



After  Splenectomy 
IV 
V 

45.61 

41  11 

4,56 

-^.ll 

i 
I 


218 


THE  SPLEEN  .VXD  .\N.EML\ 


ination  of  the  faeces  for  iron.  As  the  iron  in  human  urine 
seldom  exceeds  0.001  mg.,  the  urine  is  not  included. 
Analyses  for  iron  were  made  on  duplicate  samples  of 
dried  fa-ces  representing  periods  of  ten  days,  hefore  and 
after  splenectomy,  respectively. 

Th.us  the  first  ten  days  correspond  to  Periods  1  and  II 
and  the  second  ten  days  to  Periods  IV  and  V.  Pericxls  II 
IV,  and  V  represent  essentially  the  same  diet.  The  figures 
for  iron  intake  were  calculated  from  published  records'"^""' 
of  iron  content  of  foods,  hence  no  claim  is  made  for  the 
extreme  accuracy  of  those  figiu'cs.  They  merely  serve  to 
show  that  the  iron  content  of  the  diet  agreed  verj'  closely 
and  would  not  account  for  the  large  difference  of  output. 
Those  differences  in  output  before  and  after  splenectomy 
amounted  to  about  40  per  cent,  decrease.  That  the  large 
output  of  iron  in  the  period  before  splenectomy  is  due  to 
the  increased  elimination  of  ii'on  consequent  on  the  ex- 
cessive destruction  of  red  cells  seems  the  most  plausible 
explanation.  The  decreased  elimination  after  splenec- 
tomy, with  a  close  agreement  of  intake  and  output,  shows 
a  cutting  off  of  this  loss  and  presumably  a  return  to  normal 
elimination. 

Urobilin. — Our  interest  in  the  urobilin  problem  has 
been  limited  to  the  influence  of  the  absence  of  the  spleen 
on  the  elimination  of  this  substance.  In  the  urine  quali- 
tative tests  for  urobilin  gave  negative  results  throughout 
the  experiment.  At  one  time,  in  a  concentrated  urine,  a 
faintly  positive  reaction  was  obtained  with  Ehrlich's 
reagent.  The  large  bulk  of  this  constituent  was  in  the 
fseces.  Because  of  the  small  bulk  of  the  child's  fasces, 
and  the  necessity  of  utilizing  considerable  portions  for 
other  determinations,  the  use  of  the  wet  f<Tces  for  urobilin 


METABOLISM  STUDIES  ON  MxVN 


•19 


deterniination  was  impracticable.     The  f*ces  were  there- 
fc.re  dried  in  the  usual  way  and  placed  inuriediately  in  well- 
stoppered  bottles.     At   the  end   of  the  expernnent  the 
feces  of  Periods  I  and  II  before  splenectomy  and  IV 
and  V  after  splenectomy  were  combined  for  urobihn  esti- 
mation.   In  view  o"  the  previous  work  on  this  substance, 
it  was  to  be  expected  that  some  of  the  urobilin  would  be 
destroved,  or  that  most  of  the  urobilinogen  would  be  con- 
verted into  urobilin,  but  whether  or  not  this  took  place  we 
have  no  means  of  determining.     The  fact  re.  ^ains  that 
considerable  urobilinogen  was  still  present  at  tl        Tie  of 
analvsis.    Inasmuch,  however,  as  both  sets  of  fs..-s  were 
treated  alike,  this  was  a  more  or  less  constant  factor.  Five 
grammes  of  fsces  were  extracted  with  100  c.c.  of  acid 
alcohol  and  treated  as  descrilKMl  in  method  as  outlined 
bv  Wilbur  and  Addis."^''    The  dilution  for  total  mass  of 
fjEces  was  then  calculated.    The  dilution  follows: 

Dilution  required  for  extinction  of  urobilinogen  and 
urobilin  absorption  bands:  Periods  I  and  II  (combined), 
71,250;  Periods  IV  and  V  (combined),  7954. 

'  These  results  are  in  accord  with  those  desenbed  by 
Eppinger,^"*  who  found,  in  a  variety  of  clinical  conditions 
accompanied  by  rapid  blood  destruction,  that  the  urobilin 
in  the  stools  sank  to  normal  after  splenectomy. 

These  general  results  may  be  summarized  as  follows: 

1.  A  slight  positive  nitrogen  balance  before  splenec- 
tomy was  followed  by  an  increased  retention  eight  days 

after  operation. 

2.  The  output  of  uric  acid  showed  a  decrease  ot  47  per 

cent,  after  operation. 

3    In  the  period  directly  after  operation  a  change  in 
the  partition  of  creatinin  and  creatin  elimination  occurred, 


s«o 


TIIE  SPLEEN  AND  AN.EML\ 


the  total  creatinin,  liowtvcr,  showin^r  l^it  slight  change. 

i.  Other  urinary  nitro^rt-n  eonstituents  showed  no  vari- 
ations from  the  normal,  and  no  ehange  was  found  in  the 
hydro^ren  ion  eoncentratio  . 

5.  The  utilization  of  nitro^ren  was  ^mod  at  all  times. 

fi.  P'at  metabolism  was  normal. 

7.  There  was  a  large  loss  of  iron  through  the  f;cees 
before  spleneetomy,  followed  by  a  decided  decrease  (40 
per  cent.)   after  operation. 

8.  The  excretion  of  urobilinogen  and  urobilin  in  the 
fjpces  was  marke<lly  diminished  after  splenectomy;  the 
amount  after  operation  was  about  one-ninth  of  that  ex- 
creted before  splenectomy. 

In  Pkrxicious  AN.T-;AnA 
The  second  study  ''"  to  be  ])resented  as  a  corollary  to 
the  above  investigation  has  to  do  with  certain  phases  of 
metabolism  in  an  individual  with  pernicious  .iiKemia  char- 
acterized by  increased  hfvmolysis.  The  studv  was  limited 
to  the  total  nitrogen,  the  uric  acid,  the  iron,"  and  the  uro- 
bilin and  urobilinf)gen— substances  in  connection  with  which 
changes  have  been  observed  in  the  studv  of  congenital 
ha-molytic  icterus.  Three  periods  were  studied:  o"ie  be- 
fore the  transfusion  and  splenectomv.  (me  two  weeks  er 
splenectomy,  and  the  third  two  weeks  later.  During  each 
period  the  paticTit  was  on  a  carefully  controller!  Folin 
metabolic  diet,  and  the  period  was  not  commenced  until 
the  patient  had  reached  an  approximate  nitrogen  balance. 
The  nitrogen  of  the  fmnl  and  urine  was  determined  l)y  the 
Kjeldahl-Gunning  method,  the  uric  acid  according  to 
Folin's  permangnnate  method,  the  iron  by  Xeumann's 
method,  and  the  urobilin  and  urobilinogen^  according  to 


META150LISM .STUDIES  ON  MAN 


221 


the  imthod  of  Wilbur  iuid  Addis.  Only  ne<rlinrible  amounts 
of  urobilin  or  urobilinogen  were  at  any  time   found  in 

the  urine. 

tablp:  lviii 

Blood  Examixatio.ns  in  a  Case  ok  I'KKMciors  An.«mia  Before  and  After 

Splknectomy 


Date 


'glcliin,  I    Er>'thr<>-     l-puk" 
piT      i        cytea  cytfs 

lunt.    : 


Nnrl<>ate<i 
iT>  thrill  5  tl'S 


I     lated 
I  erythro- 
I     cytes, 
!  per  cent 


3/28/15       26 


4/  S/15 
4  15/15 

5/  3/15 

6/  5/15  i 
1 
6/  7/15 
6/  8  15 
ti/lJ  15 
G/I5  15 
6  21/15 
6,24/15 

6,24/15 

6 '28/15 
7/  9/15 
7/15/15 

7/22/15 
7/30/ 15 
8/  6/15 
8/16/15 
8/24/15 
8/29/15 
8/30/15 
1/  8/16 


1,150,000  4,6(U)  .\onnobl!vsfs  + 
Mep:ili)l)lii.sts  + 
25  I  1,620,000,  5,S00  Meg:il<)l)lasts  + 
20      1,110,000    2,000  0 


20     !  1,700,000 

i 

28      1,300,000 


6,500,  0 

4,300  N'orni()l>lasts  + 


2 
1 


Kcrnarka 


40'    I  1,810,000    3,800] 


0 


37     11,420,000  16,600' 

40     1 2,930,000  12,000  Xormobhusta  i-  + 


28 
31 
35 

48 
55 
69 
48 
54 
70 

83' 


1,640,(XK»  3,700  .\onnnl)l!i.sts  + 
l.t):;0,(HH)i   6,300,  0 

2.370,(XK);   6,000  XornioMiusts  + 
I  MeKul()lilast,s  + 

2,030,(K)0  S.IOO  Xorinoblaf-ts-l- 
2,570,()00|  7,100,  .Nornioblaala  + 
2,3(X1,0<K)l  9,100  Normoblaste  + 
3.20O.(KK)    ,s,3(K)i  0 

S,4(X)  0 

9,400,  0 


3,700,(HX1 
3,580,000 


4,400,000:10,500 


Normobla.st, 
occasional 


CoaRultition  time, 
4.5  iiiin. 

Ha'niolysis  in  NaCl: 
partial  0.425,  com- 
plete 0.325 

Ijcft  hospital  for  u 
month 

Platelets  Ies.s  than 
lOO.(KK) 

Transi'iLsion  900  c.c. 

Splenectomy 


Severe  hai-inorrhagc 
from  throat 

After  the  haemorr- 
hage 


HowcU-JoUy  bodies  + 


Discharged 
Count  by  Dr.  S.  L. 
Freeman 


*  The  differential  counts  of  the  leukocytes  always  showed  a  aliKht  eoainophilm,  but  were 
othBrwi.M  normal.  The  erythro.-vtcs  showe.l  the  changes  characteristic  of  severe  anemia; 
Ih.ist:  became  leas  marked  as  the  antemia  disappeared. 

The  history  and  findings  in  the  case  will  be  given 
bnefly.  The  blood  examinations  are  tabulated  in  Table 
LVlil  and  the  metabolic  results  in  Table  LIX. 


822 


THE  SPLEExN  AND  ANEMIA 


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MET  A  HOLISM  STUDIES  ON  >LVN 


as 


Cliniad  Sotcs.—  'Yhe  patient,  a  luati,  aged  forty,  had 
coniplaiiifd  for  twf)  years  of  weakness,  dizziness,  dyspna'a, 
and  anlenia.  These  symptoms  were  stea<hly  iRcoming 
worse.  In  other  respects  his  history  is  unimportant.  The 
physical  examination  revealed  nothing  noteworthy  other 
than  the  signs  of  intense  ana-mia,  associated  with  a  lemon- 
yellow  pallor.  The  liver-edge  was  jnst  palpahle.  At 
operation  the  spleen  was  found  to  he  alxiut  three  times 
its  normal  size,  weighing  340  gms.  The  pathologic  ex- 
amination of  the  spleen  showed  chronic  diffuse  and  fol- 
licular hyperplastic  splenitis,  with  passive  congestion  and 
excessive  pigmentation.  The  Wassermann  was  negative. 
On  account  of  a  constant  eosinophilia.  repeated  careful 
examinations  were  made  of  the  stcxils  for  ova  or  para- 
sites, hut  with  negative  results.  The  other  lahoratory 
reports  are  unimportant.  The  patient  improved  gradually 
after  the  splenectomy,  and  six  months  later  was  doing 
fairly  arduous  work,  apparently  in  perfect  health. 

The  figures  as  given  in  Tahle  LIX  show  that  but 
little  cliange  in  the  elimination  of  uric  acid  and  iron  took 
place  as  a  result  of  the  splenectomy.  The  direction  of 
the  changes  is,  however,  in  each  instance,  in  accord  with 
the  more  pronounced  changes  in  the  study  of  congenital 
ha?molytic  jaundice,  in  which  the  hfemolytic  factor  is  more 
marked. 

In  view  of  the  fact  that  the  nitrogen  balance  is  prac- 
tically identical  in  the  first  and  third  periods,  it  may  be 
concluded  that  splenectomy  in  this  case,  as  in  other  cases 
reported  in  the  literature,  has  no  permanent  effect  on  the 
total  nitrogen  balance.  The  distinct  positive  balance  dur- 
ing the  second  period  is  of  interest,  but  probably  of  no 
significance  in  relation  to  splenic  function.     The  uric- 


) 


iu 


THE  SPLEEN  AND  AX.EMIA 


acid  tliiiiinatioii  licf'ore  operation  caiuiot  Ik?  said  to  Ik- 
other  tliaii  a  lii^h  nonnal  li<rure,  and  tlie  lower  post-opera- 
tive fiy-ures  are  still  within  normal  rrji^e;  hut  when  it  is 
considered  that  the  diet  and  rtfifinie  in  general  were  iden- 
tical het'ore  and  after  operation,  the  lowered  output  after 
operation  is  definite  and  significant.  The  same  can  l)e 
said  of  the  figures  for  the  iron  elimination. 

In  the  combined  urobilin  and  urobilinogen  elimination 
a  definite  change  is  noted  following  the  splenectomy.  Two 
weeks  after  splenectomy  the  diminution  in  the  urobilin 
output  was  negligible,  the  lifference  between  18,300  units 
per  day  and  1(>,0()0  l)eing  too  slight  to  permit  of  signifi- 
cance l)eing  attached  to  it.  Two  months  after  splenec- 
tomy, however,  at  a  time  when  the  bl(x)d  count  showed  a 
pronounced  and  most  satisfactory  improvement,  the  uro- 
bilin output  had  fallen  to  one-seventh  of  its  former  figure 
and  had  reached  a  low  normal  elimination. 

These  observations  may  be  summarized  briefly  as 
follows : 

1.  A  slight  positive  nitrogen  balance  before  splenec- 
tomy was  followed  by  an  increased  nitrogen  retention 
fourteen  days  after  operation  and  a  return  to  the  pre- 
operative balance  after  one  month. 

2.  The  output  of  uric  acid,  although  never  exceeding 
normal  limits,  showed  a  decrease  of  22  per  cent,  after 
operation. 

3.  The  output  of  iron  through  the  fjtces,  although  never 
above  normal,  showed  a  decrease  of  40  per  cent,  after 
operation. 

4.  The  excretion  of  urobilinogen  and  urobilin  in  the 
faeces  before  splenectomy  was  about  three  times  the  nor- 
mal; two  months  after  operation  the  output  was  about 
one-seventh  of  that  before  splenectomy. 


METABOLISM  STLUIES  ON  .NLVN 


iio 


Discussion 

The  literature  concerning  the  relation  of  the  spleen  to 
inetaholisni  may  he  considered  under  five  heads:  (1) 
Studies  hoth  hefore  and  after  splenectomy  for  disease  of 
the  spleen  in  man;  (2)  studies  in  man  after  splenectomy; 
(3)  studies  of  eon<^enital  hirmolytic  jaundice;  ( i')  studies 
of  anannia;  ('))  studies  of  the  effect  of  removal  of  the 
normal  spleen. 

1.  In  only  three  instances  other  than  those  reported 
uhove  have  nietaholic  studies  heen  made  hoth  hefore  and 
after  splenectomy  for  diseases  of  the  spleen  in  man.   Two 
of  these  are  T^mher's  studies  of  lianti's  disease,  and  the 
third  Minot's  study  of  pernicious  nna'mia.    Umher  studied 
two  individuals  splenectomized   for  Banti's  disease,   and 
Minot  one  in  whom  the  spleen  was  removed  as  a  last  resort 
in  j)ernieious  ana^nia.    One  of  Pml)er's  sahjeets''**  was  a 
hoy  of  fifteen  with  ana'inia  and  icterus.    The  post-operative 
period  of  study  covered  twelve  days  and  he^^an  twenty- 
four  days  after  the  operation.     The  diet  was  pui in-free, 
and  a  fully-controlled  metaholie  study  was  made.     The 
results  showed  no  pronounced  variation  in  the  distrihution 
of  the  urinary  cynstituents  which  could  he  attrlhuted  to 
the  ahsence  of  the  spleen.     Umher  makes  a  point,  how- 
ever, of  the  fact  that  after  removal  of  the  spleei    it  was 
easier  to  ohtain  n'trogen  equilihrium,  and  attrihuted  the 
pre-operative  pathologic  destruction  of  protein  to  a  toxic 
cause.     His  figures  show  also  a  somewhat  greater  output 
of  j)urins  hefore  the  operation  than  after.     Tn  another 
case  of  Banti's   disease   descrihed   in   this   report  ***   the 
"  toxic  "  disturbance  of  metabolism  was  not  present  and 
splenectomy  was  not  done.     In  a  later  study***  Uml^er 

describes  a  young  man  of  twentv-one  suffering  from  what 
16 


226 


THE  splee::  and  anemia 


he  considers  as  the  "  toxic  "  type  of  Banti's  disease.  Sple- 
nectomy led  to  striking  improvement.  The  metabolism 
study  of  this  case  was  limited  to  a  comparison  of  total 
nitrogen  intake  and  output  before  and  after  splenectomy. 
The  results  confirm  his  former  observation,  namely,  that  a 
persistent  negative  balance  before  splenectomy  changes  to  a 
positive  balance  after  splenectomy.  The  post-splenectomy 
study  was  made  three  months  after  operation.  Minot's  ^^^ 
patient  was  a  colored  woman,  aged  thirty-five,  on  whom 
the  second  period  of  metabolic  studies  were  begun  fifteen 
days  aft',  -  splenectomy  and  blood  transfusion.  The  figures 
given  for  five  twenty-four-hour  periods  before  and  six  after 
splenectomy  are  not  for  consecutive  days.  The  examina- 
tion included  total  nitrogen  in  urine  and  fseces,  and  urea 
and  ammonia  in  the  urine.  The  chief  results  were  a  change 
from  a  slight  negative  to  a  slight  positive  nitrogen  balance 
and  an  increase  in  percentage  of  urea  after  splenectomy. 
The  uncertaincy  of  the  food  intake  in  the  period  before 
splenectomy,  the  low  caloric  intake,  and  the  shortness  of 
consecutive  periods  of  observation  make  these  balances 
of  doubtful  value. 

2.  The  following  studies  made  after  splenectomy  have 
no  fore-period  for  comparison.  Lo  Monaco  "'"^  found  in 
a  splenectomized  individual  no  important  change  in  uric- 
acid  elimination. 

IVfondel  and  Gibson,^®*  in  the  case  of  a  man  with 
enlarged  spleen  and  secondary  ansemia  following  malaria, 
studied  the  metabolism  (total  nitrogen,  urea,  uric  acid, 
ammonia,  phosphorus,  chlorides,  and  sulphates)  after 
splenectomy,  but  found  no  striking  variation  from  the 
normal  distribution  of  the  urinary  components. 

Likewise,  Moraczewski,'^"^  who  made  some  stac'es  of 


METABOLISM  STUDIES  ON  MAN 


227 


-X 


both  nitrogenous  and  mineral  metabolism  in  a  man  of 
tifty-one,  seven  months  after  splenectomy  for  "  spleen 
tumor"  (malarial),  fomid  no  important  variations.  His 
observations,  however,  were  few  in  number  and  were  made 
in  the  course  of  an  attack  of  pneumonia  which  rendered 
matters  of  diet  and  control  difficult. 

3.  The  only  carefully-conducted  and  complete  study  of 
the  metabolism  in  congenital  ha?molytic  icterus  is,  so  far 
as  we  are  a^are,  that  of  McKelvy  and  Rosenbloom.^®^ 
The  patient,  a  girl  aged  eleven,  on  a  Folin  diet,  was  studied 
for  six  days.     The  total  nitrogen,  fat,  and  mineral  con- 
stituents of  the  food  were  determined  and  both  urine  and 
fa?ces  stuu.^d  as  to  nitrogenous  and  mineral  constituents 
and  the  fa-ces  as  to  fat.    During  a  period  of  six  days  there 
was  a  loss  of  4.06  gms.  of  nitrogen,  which  the  authors  sug- 
gest may  be  due  to  a  toxogenic  destruction  of  protein. 
The  nitrogen  partition  of  the  urine  was  nonnal  except  in 
the  case  of  the  uric-acid  nitrogen,  which  was  increased. 
This  increase,  the  writers  state,  might  be  due  to  the  in- 
creased, liberation  of  nucleoproteins  through  haemolysis 
of  the  er>'throcytes.     The  study  of  mineral  metabolism 
showed  a  loss  of  sulphur,  iron,  calcium,  and  magnesium, 
and   a   retention   of   phosphorus.      The   fat   metabolism 
was  normal.      No  metabolism  studies  were  made  after 
splenectomy. 

In  a  woman,  aged  thirty-nine,  with  "chronic  family 
javmdice,"  Tileston  and  Griffen'^''  studied,  for  three  suc- 
cessive days  md  an  added  odd  day,  the  output  of  am- 
monia, urea,  creatin,  and  creatinin  on  a  purin-free  and 
creatin-free  diet.  They  found  the  elimination  of  creatinin 
and  urea  to  be  essentially  normal,  ammonia  somewhat  high, 
and  uric  acid  distinctly  increased.    However,  it  should  be 


228 


TTiE  SPLEEN  AND  AN.EMIA 


notetl  t?iat  only  one  deterniination  of  uric  acid  was  made. 
Ilaal,""  in  a  case  v.f  family  ha-niolytic  jaundice,  found 
an  increased  excretion  of  uric  acid  and  of  iron. 

4.  As  the  changes  :i  metabolism  in  various  types  of 
anaemia  have  recently  been  summarized  by  Minot,  we  will 
not  present  this  literature  in  detail.  The  opposing  views 
are  represented  by  Rosenqvist  and  von  Xoorden.  Rosen- 
qvist,'*'**  in  pernicious  ana^nia  and  bothriwephalus  ana-mia, 
found  variations  in  nitrogen  elimination,  with  periods  of 
alternate  increased  and  decreased  excretion.  In  bothrio- 
cephalus  anamiia  a  well-marked  loss  of  nitrogen,  while  the 
worm  was  in  the  l)ody,  was  followed,  after  removal  of 
the  worm,  by  a  nitrogen  retention.  Rosenqvist  concluded 
that  in  both  types  of  ana'inia  a  pathologic  decomposition 
of  protein  is  present.  Von  Xoorden  ^'''  opposes  this  view, 
and  as  a  result  of  his  studies  concludes  that  protein  de- 
composition is  not  increased  as  the  result  of  ana'mia  of 
the  ordinary  type.  The  variations  in  output,  he  believes, 
may  be  explained  by  the  alimentary  and  renal  disturbances 
which  accompany  ana-mia.  That  an  increased  output  of 
nitrogen  may  occur  in  ana^nia  due  to  parasites  is  admitted, 
as  is  also  the  possibility  in  non-parasitic  ana^nias  of  a 
temporary  increase  in  the  output  of  nitrogen  as  the  result 
of  a  sudden  destruction  of  large  masses  of  red  cells. 

As  to  uric-acid  output,  von  Xoorden  refers  to  Rosen- 
qvist's  high  figures  and  to  other  observations  and  concludes 
that,  as  a  rule,  in  ana?niia  the  out])ut  is  normal,  but  some- 
times rises,  as  in  Rosenqvist's  work,  to  twice  the  normal 
amount. 

It  is  notewortliy  that  in  lK)thriocephalus  ana>mia  Rosen- 
qvist found  that  after  removal  of  the  parasite  the  puriu 
output  increased  temporarily  and  then  returned  to  normal. 
This  temporary  increase  lie  explains  as  due  to  the  regen- 


IVIETABOLISM  STUDIES  ON  AL\X 


229 


eration  and  incrensed  metabolic  activity  of  the  blood  and 
somatic  cells  consequent  on  the  removal  of  the  toxic  afjfent. 
As  the  cells  recovered  their  normal  equilibrium  the  output 
of  the  purins  fell  to  normal  level. 

Halpern/"''  studying  one  case  of  pernicious  anfpmia 
and  one  of  splenic  ansemia,  found  normal  values  for  the 
various  urinary  constituents.  His  figures  for  purin  output 
are  in  no  way  abnormal. 

Samuely,*"'  in  his  studies  of  metabolism  in  dogs  ren- 
dered ansemic  by  poisoning  with  pyrodin,  found  no  essential 
changes  in  protein  metabolism. 

5.  The  literature  of  splenectomy  in  man  for  conditions 
(»ther  than  chronic  antemia,  as,  for  example,  gunshot 
wound,  rupture,  cyst,  etc.,  shows  that  no  metabolism 
studies  have  been  made  in  such  conditions.  Conclusions 
concerning  the  effect  on  metabolism  of  removal  of  the 
normal  spleens  in  the  normal  individual  must  therefore  be 
based  on  observations  on  animals. 

Metabolic  studies  before  and  after  splenectomy  in 
animals,  as  we  have  shown  elsewhere  (see  p.  181),  indicate 
that  the  removal  of  the  spleen  does  not  influence  protein 
metabolism. 

As  to  metabolism  studies  of  substances  other  than  pro- 
tein and  its  derivatives,  the  same  paucity  of  data  exists. 

The  literature  contains  no  records  of  the  examination 
of  the  fa-ces  for  fat  before  and  after  splenectomy.  Tiles- 
ton  and  Griffen,  in  one  of  their  cases  of  chronic  family 
jaundice,  studied,  without  result,  the  fats  of  a  single  stool. 
McKelvy  and  Rosenbloom,  in  their  case  of  congenital 
hapmolytic  jaundice,  report  normal  fat  metabolism. 

The  literature  of  iron  metabolism  is,  at  best,  unsatis- 
factorv',  and  this  is  especially  true  of  work  on  the  relation 


230  THE  SPLEEN  AM)  .VN^MU 

of  the  spleen  to  iron  metabolism.  Most  of  the  work  is 
based  on  Sehmidt's  •''■'''  conclusions,  drawn  from  the  results 
of  the  feeding  of  iron-p(K)r  food  to  normal  mice,  that  the  or- 
ganism possesses  great  power  of  consen-ing  the  iron  and 
of  reutilizing  it  through  some  form  of  intermediary  metab- 
olism. In  this  connection  Schmidt  regards  the  liver  as  the 
depot  for  iron  from  the  foml,  and  the  spleen  as  the  depot 
for  iron  from  tissue  and  erythrocyte  catabolism. 

The  experimental  evidence  concerning  the  relation  of 
the  spleen  to  iron  metabolism,  which  we  have  described  in 
detail  elsewhere  (see  p.  112),  is  contradictory.  Asher 
and  his  associates,  (Jrossenbacher '"  and  Zimmermann,''-' 
claim  that  the  dog  after  splenectomv  eliminates  an  in- 
creased amount  of  iron.  Our  observations  do  not  support 
these  findings.  In  our  early  work  we  occasionally  found 
a  slight  increase  in  the  faeces  one  and  two  weeks  after 
splenectomy,  but  in  later  studies  an  increase  was  never 
found  except  once  in  an  anaemic  animal.  We  are  therefore 
inclined  to  view  a  disturbance  of  iron  elimination  in  the 
dog  as  due  to  an  associated  ana-mia  rather  than  to  the 
disturbance  of  some  splenic  function. 

No  observations  in  man,  other  than  our  own  ( see  Table 
LX)  on  iron  eliminr.tion  both  before  and  after  splenec- 
tomy, are  at  hand.  IJayer,''"  in  the  study  of  iron  elimina- 
tion after  si)lei!ectomy  for  (1)  rupture  of  the  spleen  and 
(2)  Banti's  disease,  comjiared  his  results  with  those  ob- 
tained in  normal  individuals.  He  found  an  increased  <nit- 
put  soon  after  splenectomy  in  the  case  of  spleen  rupture, 
but  later  the  elimination  returned  to  normal;  in  the  ease 
of  Banti's  disease  the  elimination  did  not  differ  from  the 
normal  controls.  A  similar  study  has  been  made  by 
Roth  ■^"''  with  like  results:    iron  elimination  was  studied 


METABOLISM  STUDIES  ON  MAN 


2S1 


in  (1)  a  man,  twenty-six  years  of  age,  whose  spleen  had 
been  removed  three  years  before  because  of  splenomegaly 
associated  with  a  type  of  ha^molytic  jaundice,  presumably 
congenital,  and  (2)  a  man,  thirty-seven  years  old,  whose 
spleen  had  been  extirpated  one  month  before  for  rupture 
due  to  trauma.    On  both  low  and  high  iron  diets  the  amount 
of  iron  absorbed  by  each,  in  relation  to  an  estimated  intake, 
was  practicallv  the  same,  but  the  output  in  the  second 
individual  was" twice  that  of  the  first;  thus  on  the  same  iron 
intake  the  former  eliminated  6.25  mgm.  and  the  latter  12.18 
mgm.  per  day.    These  figures  are  in  accord  with  the  ex- 
treme for  normal  individuals,  but  one  cannot  avoid  a  query 
as  to  whether  the  time  elapse<l  since  splenectomy,  three 
vears  as  compared  to  one  month,  is  not  a  factor  in  the 
Widely   different    figures,    or,    again,    whether   the   ear- 
lier anaemia  in  the  first  case  may  have  been  a  factor. 
Indeed,  the  paucity  of  iron  figures  and  the  wide  vari- 
ation   in    figures    for    normal    individuals    render    their 
interpretation  exceedingly  difficult.    This  may  be  seen  in 
Table  LX,  in  which  we  have  grouped  all  analyses,  for 
normal  and  anaemic  individuals,  which  we  have  been  able 
to  collect  from  the  literature.    McKelvy  and  Rosenbloom's 
studies  of  congenital  haemolytic  jaundice  before  splenec- 
tomy show,  as  do  ours,  that  the  elimination  of  iron  in  this 
disease  is,  on  the  basis  of  normal  figures  in  the  literature, 
increased'.    This  increase  they  explain  as  due  to  the  great 
destruction  of  red  cells. 

From  a  review  of  the  literature  it  is  evident  that  in 
anjemia,  with  or  without  splenic  disease,  the  majority  of 
investigators  have  experienced  difficulty  in  obtaining  a 
nitrogen  balance.  Umber,**'  in  his  study  of  Banti's  dis- 
ease; Minot.'"''  in  pernicious  anwmia;  McKelvy  and  Rosen- 


isi 


THE  SPLEEN  AND  AN^ML\ 


blooin,^-  in  congenital  haemolytic  icterus,  and  Rosen- 
qvist,"^^  in  pernicious  antemia  and  bothriocephalus  ana»niia, 
all  report  a  pathologic  destruction  of  protein.  Umber  **^ 
goes  so  far  as  to  urge  this  "  toxic  destruction  "  as  a  cri- 
terion for  operation.*  Von  Xoorden  '"'  alone  opposes  this 
theory  of  increased  destruction  of  protein  in  aruuniia.  In 
the  two  cases  we  report,  no  difficulty  was  experienced  in 
obtaining  a  positive  nitrogen  balance  before  operation: 
feeding  was  not  forced,  the  patients  merely  satisfying  their 
natural  desires  for  food.  Nevertheless,  the  increased  re- 
tention immediately  after  the  operation  on  the  same  nitro- 
gen intake  would  appear  to  support  the  theory  that  some 
toxogenlc  influence  had  been  removed.  To  this  influence, 
however,  must  be  added  as  a  cause  of  retention  the  higher 
level  of  reparative  processes  g^ing  on  in  the  body,  as,  for 
example,  in  the  bone-marrow  and  possibly  other  organs. 
It  is,  however,  difficult  to  reconcile  our  slight  positive 
balance  with  Umber's  marked  negative  balance,  before 
operation. 

As  regards  the  elimination  of  uric  acid  in  anaemia,  with 
or  without  disease  of  the  spleen,  one  finds  the  general 
view  to  be  that  the  elimination  is  high.  Rosenqvist  (in 
1903),  as  a  result  of  his  studies  of  pernicious  ansmia  and 
bothriocephalus  anaemia,  reports  large  outputs  of  uric  acid, 
sometimes  twice  the  normal  amount.  He  finds  that  after 
the  removal  of  the  worm  in  the  latter  condition  there  is 
first  an  increased  elimination  of  purins  and  then  a  return 
to  the  normal.  His  explanation  for  this  is  an  increased 
metabolic  activity  of  the  blood  and  somatic  cells  following 
the  removal  of  the  toxic  agent.    In  our  case,  after  removal 

»  Luce,"'  Miiller,''"  Ix)inmcl,="  (Irosscr  and  Schaub,""  have 
failed  to  find  an  increased  destruction  of  protein  in  Banti's  disease. 


METABOLISM  STUDIES  ON  MAN 


23S 


(if  the  spleen,  we  found  the  reverse  condition — an  imme- 
diate drop  to  normal.  That  in  our  first  case  an  increase 
took  place  between  the  time  of  operation  and  the  beginning 
of  our  first  post-splenectomy  period  (eight  days  after 
operation)  we  cannot  say.  When,  however,  one  inspects 
the  results  of  blood  examination  after  operation,  it  is  ob- 
served that  the  increase  in  red  cells  and  hemoglobin  was 
steady  and  gradual,  no  greater  during  the  first  eight  daj's 
after  operation  than  during  the  subsequent  ten  days  of 
our  metabolism  period,  so  that  regenerative  processes  were 
at  best  gradual. 

Umber,  in  his  studies,  does  not  report  uric-acid  output, 
but  groups  his  findings  under  total  purins,  of  which  he 
found,  in  Banti's  disease,  a  somewhat  greater  output  before 
o])eration  than  after.  Haal,  in  family  hsemolytic  jaun- 
dice, found  an  increased  excretion  of  uric  acid.  Von  Noor- 
den  gives  as  his  opinion,  based  on  a  review  of  the  literature, 
that  in  anaemia  the  output  may  be  normal,  but  is  sometimes 
increased.  I^o  Monaco,  and  Mendel  and  Gibson  report  no 
change  in  uric-acid  excretion  after  splenectomy,  but  pre- 
sent no  pre-splenectomy  studies  for  comparison. 

In  congenital  haemolytic  icterus  McKelvy  and  Rosen- 
bloom  report  higher  uric-acid  output,  b'u^  present  no  studies 
after  splenectomy.  They  give  as  an  explanation  for  the 
increased  output  the  greater  formation  of  nucleoprotein 
resulting  from  the  destruction  of  red  cells.  Their  explana- 
tion seems  to  be  ina<lequate,  for  it  is  difficult  to  imagine 
the  destruction  of  red  cells  as  being  the  sole  source  of 
this  large  output  of  purin.  It  may,  to  some  extent,  be  a 
factor,  but  the  toxic  influence  on  the  somatic  cells  gen- 
erally of  bile  products  would  appear  to  be  a  factor  of 
greater  importance.    The  sallow  discoloration  of  the  skin 


2S4 


THE  SPLEEN  AND  ANAEMIA 


in  the  disease  is  indicative  of  the  general  dissemination  of  a 
substance  absorbed  directly  or  indirectly  from  the  bile,  and 
our  knowledge  of  the  toxic  influence  of  bile  constituents 
offers  a  possible  explanation  for  a  widespread  state  of 
cell  degeneration  and  consequent  repair  which  would 
account  for  increased  output  of  products  of  nuclein 
metabolism. 

The  only  experimental  studies  which  seem  to  have  any 
bearing  on  this  problem  of  protein  metabolism  are  those 
of  Jackson  and  Pearce,^""  who  used  ha?molytic  immune 
senmi  to  produce  liver  necrosis  and  made  detailed  studies 
of  associated  changes  in  metabolism.  The  changes  caused 
by  ha?moh'tic  seruni — anosmia,  jaundice,  and  cell  degen- 
eration— represent  as  close  an  approach,  aside  from  chro- 
nicity  to  conditions  in  congenital  haemoh'tic  jaundice  as 
can  be  brought  about  experimentally.  It  is  of  interest 
that  under  such  experimental  conditions  an  increased  out- 
put of  total  nitrogen,  rest  nitrogen,  purins,  and  phosphorus 
was  obser\'ed.  These  changes  were  explained  as  due  to 
cell  autolysis  consequent  upon  the  necrosis  of  liver  tissue ; 
when  the  necrosis  was  absent,  little  metabolic  change  was 
evide.it.  It  is  impossible  to  make  an  exact  parallel  between 
an  acute  experimental  lesion  in  animals  and  a  chronic  dis- 
ease in  man,  especially  as  the  pathologj^  of  congenital 
ha>molytic  jaundice  offers  no  evidence  of  focal  liver  ne- 
crosis, but  in  view  of  the  attempts  of  the  several  investiga- 
tors we  have  quoted  to  show  a  toxic  destruction  of  tissue 
in  hjemolytic  ana?mias,  the  experimental  studies  of  Jack- 
son and  Pearce  are  suggestive. 

The  Improvement  in  functional  equilibrium  after  sple- 
nectomy, showTi  by  the  studies  of  protein  metabolism,  are 
emphasized  by  the  studies  of  the  exchange  of  iron.    Our 


METABOLISM  STUDIES  ON  MAN 


235 


findings  in  congenital  ha-niolytic  jaundice  and  perniciouN 
anannia  can  be  explaineil,  when  compared  with  the  direct 
blood  examination,  only  on  the  basis  of  an  increased  blood 
destruction  before  splenectomy  and  the  removal  of  a  hemo- 
lytic factor  by  the  operation.     And  this  view  is  tenable 
despite  the  fact  that  the  figures  for  iron  elimination  iK-fore 
splenectomy  are  well  within  those  given  for  normal  indi- 
viduals (see  Table  LX).     A  study  of  figures  for  intake 
and  output  of  iron  and  of  elimination  before  and  after 
operation  leaves  no  doubt  as  to  the  influence  on  the  iron 
exchange.    Our  results  cannot  be  brought  into  relation  with 
other  investigations,  as  in  no  studies  before  ours  has  iron 
elimination  been  studied  both  before  and  after  splenectomy. 
The  results  of  our  study  of  urobilin  are  in  accord  with 
the  older  views  as  to  the  source  of  this  substance   (that 
is,  excessive  blood  destruction) ,  and  also  with  the  views  of 
Eppinger  concerning  the  decrease  of  urobilin  after  sple- 
nectomy in  various  diseases  of  the  blood.     The  study  of 
urobilin  elimination  has  become  a  matter  of  considerable 
importance  in  prognosis  after  splenectomy.    Its  increased 
elimination  is  usually  associated  with  other  evidences  of  in- 
creased hemolysis,  as  high  excretion  of  iron  and  uric  acid 
and  a  discoloration  of  the  skin,  and  its  decrease  after  sple- 
nectomy is  considered  as  indicative  of  the  checking  of 
hemolysis  and  as  justifying  a  favorable  prognosis.    This  is 
particularly  true  of  congenital  hemolytic  jaundice,  but 
obser\-ations  concerning  urobilin  elimination  in  pernicious 
anemia  are  somewhat  contradictory.    Thus  Robertson  "^ 
emphasizes  the  fact  that  cases  which  had  shown  a  high  uro- 
bilin excretion  before    splenectomy  and  in  which,  after 
splenectomy,  the  urobilin  output  exhibited  only  a  transient 
reduction,  or  none  at  all,  did  not  show  as  much  improve- 


THE  SPLEEN  AND  ANEMIA 


TABLE  LX 
EuMiNATioN  or  Iron  l\  Healthy  and  Anaemic  Ikdividuaub 


Observer 


8ei 


Von  Wendt  "• 


Lehmann,  Muel-  Male 
ler,    Munk,      Male 

Zuntz  »* 

I 

Stockman     and  Male    I 
Greig  "« 

I  Male  II 
Female 
Male  1 
2 
3 
4 
5 
6 
7 
8 

y 

Male 
Male 
Male 
Female 


Shennan «" 


McKelvy    and 
Rosenbloom*^ 


Roth  '• Male 


Bayer ' 


Male 
Male 

Male 
Male 

Female 
Female 
Female 


> 

Iron  in  niKm. 

Remarks 

Intake 

Output 

per  day 

pe.  day 

26     i  Fasting 

7.3   "- 

I*rofes.sional    fastens;    10 

21     1  Fasting 

7.7 

and  6  day  i)criodu  re- 
spectively 

20          62*' 

6.32*< 

Healthy  individuals 

5.6 

U.46« 

i5           6.2 

8.33 

23     1      .•i.5 

3.73 

11.0  •' 

9.0'* 

Xine  periods  of  observa- 

.    :      6.0 

11.0 

tion  on  two  healthy  m- 

.     1     10.0 

14.0 

dividuals 

.     1      s.o 

9.0 

.  :  17.0 

42.0 

■   ;    "" 

15.0 

.     f     19.0 

24.0 

.     J    28.0 

34.0 

.     ;    27.0 

32.0 

.  :   5.7  •' 

5.5  •« 

Three  healthy  individuals 

.     '■      6.5 

8.7 

■     1      7.1 

12.6 

1 

1     !      8.8  •' 

32.51** 

Congenital    hsemolytic 
jaundic^e — 5  day  fwriod 

r 

'6         90.0  •» 

6.25** 

Ha;molytio  ana;mia.  Sple- 

150.0 

4.32 

nectomized  3  years  pre- 
viously 

* 

7     1    90.0 

12.18 

Splenectomized     one 

:  200.0 

33.07 

month    previously    for 
trauma  of  gplocn 
Two  weeks  after  spleneo- 

1 

6       240.0  ♦' 

9.38  »» 

140.0 

7.41 

tttay     for     traumatic 

130.0 

14.54 

spleen  rupture.     Three 

80.0 

5.92 

montlis  later 

300.0 

26.73 

1 

6       240.0 

8.40 

Control:        Fracture    of 

!  140.0 

7.20      1 

tibia 

1 

6       130.0 

8.57 

Control:     Osteomyelitis; 

80.0 

3.57 

operation   14  days   be- 

300.0 

23.49 

fore 

1 

9       130.0 

13.86 

Morbus  Ranti;  2X  years 
after  splenectomy 

2 

5       130.0 

i 

10.20 

MorbiLs   Lanti;   }'2  year 
after  splenectomy 

2 

7    1    60.0 

21.46 

1 

Morbus  Basedow;  before 
thymectomy 

i    60.0       i 

32.70      1 

Three  weeks  after 

METABOLISM  STUDIES  ON  MAN- 
TABLE  LX—("onlinued 
EUMINATION  or  Iron  in  Healthy  and  Anjuiic  iNDiviDnALa 


237 


1 

Iron  in 

mem. 

Obwrver 

S^i         ' 

Hemark-* 

•   *       1 

1 

Intake 

Output 

per  day 

per  day 

60.0 

I2.s;j 

Six  weeks  after 

60.0 

19.00 

Ten  weeks  after 

Male 

22 

130.0 

3.59 

Morbus  Uanti ;  before 
Hpleuectoiuy 

Goldschmidt, 
I'cpiRT     and 
Pearcc  "» 

Male 

5 

3.77*» 

8.29« 

Congenital    hymolytic 
jaundice.     Before  sple- 
nectomy.  10dayi)eriod 

4.56 

4.11 

After  .splenectomy,  10  day 

period 

Pepper  and  Aus- 
tin»« 

Male 

40 

16.5  •" 

17.0  " 

PernicioiLS  ana-mia.  Be- 
fore solenectomy,  5  day 
period 

16.5 

10.0 

Two  weekf  after  splenec- 

tomy, 4  day  period 

•1  Trnn  intake  dptPrmin**'!  by  artuftl  analysis  .         .    .       ■  .        ;„  <;-.* 

«  Tw"  piM^ods  on  sTmo  .ndivi.lua!;    bulk  uf  f«ce8  in  second  penod  tw.c-e  ».  great  a.  m  fimt. 
••  Iron  intake  estimated  from  tablin 
••  Urine  and  fxcea. 
•»  Feces  only. 

ment  in  other  respects  as  did  those  cases  in  which  the 
urobilin  output  was  permanently  reduced.  On  the  other 
hand,  Lee,  Vincent,  and  Robertson  "^'  state  that  in  some 
cases' of  severe  ana-niia  which  showed  marked  symptomatic 
improvement  for  several  months  after  splenectomy  there 
was  in  the  post-operative  period  a  return  to  a  continued 
high  excretion  of  urobilin. 

I^Iore  work  is  necessary  before  this  problem  can  be  con- 
sidered as  settled,  and  it^is  to  be  hoped  that  metabolism 
studies  before  and  after  splenectomy  will  include  not  only 
the  ansmias,  but  studies  in  es^ontially  normal  individuals, 
such  as  those  with  simple  lesions  of  the  spleen,  unaccom- 
panied bv  ana?mia.  Studies  of  this  latter  type  would 
eliminate  present  doubt  as  to  the  Importance  of  the  factor 
dependent  on  the  absence  of  the  function  of  the  normal 


238 


THE  SPLEEN  AM)  .VN.EMU 


spleen  and  thus  offer  the  essential  control,  now  lacking, 
for  the  correct  interpretation  of  the  nietaholic  disturbances; 
that  is,  wliether  they  are  due  to  ana-mia  or  the  diseased 
spleen,  or  both. 

For  the  present,  however,  it  seems  justifiable  to  con- 
elude  that  splenectomy  in  the  Iwrnolyiic  ana?mias  is,  as  a 
rule,  followed  by  a  reduction  in  the  elimination  of  uric 
acid,  iron,  and  urobilin,  changes  indicative  of  decreased 
destruction  of  tissue  and  blood  elements. 


^m^ 


3 

^  f 

1 

Part  II. 

CLINICAL  OBSERVATIONS  BY 
E.  B.  KRLTdBH.VAR 


CHAPTER  XI 

CLASSIFICATION  AND  ANALYSIS  OF  TYPES  OF  SPLENO- 
MEGALY ACCOMPANIED  BY  ANEMIA. 

Enlargement  of  the  spleen  is  a  common  accompani- 
inent  of  many  clinical  conditions,  but  in  this  chapter  will 
he  considered  only  such  splenomegalies  as  are  accompanied 
by  anjemia;  as,  for  example,  Banti's  disease,  splenic 
ana-mia,  Gaucher's  disease,  hsemolytic  jaundice,  and  per- 
nicious ana'mia,  conditions  in  which  the  enlarged  spleen 
seems  to  have  an  important  relation  to  the  anfemia. 

The  connection  between  chronic  enlargement  of  the 
spleen  and  marked  ansemia  without  leukocytosis,  as  de- 
noted in  the  term  "  splenic  anjemia,"  was  first  established 
fifty  years  -o  by  Gretzel,"*  in  Griesinger's  clinic,  in 
Berlin.  He  describes  the  case  of  a  child,  ten  months  old, 
sufTermg  from  dysentery  and  severe  anjemia,  with  con- 
siderable enlargement  of  the  spleen  and  a  lesser  degree 
of  enlargeinent  of  the  liver  and  l\Tnph-nodes.  Examina- 
tion of  the  blood,  by  the  crude  methods  then  in  vogue, 
showed  that  the  proportion  of  white  to  red  cells  was  not 
increased.  Although  later  authorities  have  considered  this 
to  have  been  either  a  case  of  Hodgkin's  or  of  von  Jaksch's 
disease,  it  unquestionably  served  to  differentiate  a  new 
clinical  condition;  that  is,  it  was  made  clear  that  the  disease 
in  question  was  not  leuka-mia.  Five  yeers  later  H.  C. 
Wo<jd"«  described  a  "splenic  variety"  of  pseudoleu- 
kspmia,  char  tcrized  by  greatl)-  enlarged  spleen  and  severe 
ana>mia,  h'.i.  without  leucocytosis.  Other  case  reports  of 
like  nature  appeared  from  time  to  time,  but  it  was  not 

»•  241 


fltt 


THE  SPLEEN  AND  ANEMIA 


If- 


until  1900  that  Osier's  ='='=  work  familiarized  the  English- 
speaking  public  with  the  condition  now  generally  known 
as  splenic  anaemia.  The  earlier  descriptions,  made  at  a 
time  whtii  the  pathological  anatomy  of  the  spleen  was  little 
understood  and  when  the  methods  of  examining  the  con- 
dition of  the  blood  were  very  inexact,  constituted  a  dis- 
tinct advance,  in  that  they  differentiated  a  new  type  of 
disease  previously  confounded  with  leukjemia.  The  term 
"  splenic  ana?mia "  is  now  known,  however,  to  include 
several  distinct  types,  and  its  use  should  be  restricted,  if 
not,  indeed,  discarded  entirely.  The  fact  that  in  most 
cases  the  etiology  or  pathogenesis  of  this  group  of  dis- 
eases is  not  yet  clearly  understood  is  no  more  an  argument 
for  continuing  to  group  them  imder  such  loose  terms  as 
"  splenic  anaemia  "  or  "  splenomegaly  with  anaemia  "  than 
it  would  have  been  to  continue  to  group  typhoid  fever 
with  typhus  fever  until  the  discovery  of  the  bacillus  typho- 
sus. Though  much  still  remains  to  be  learned  in  regard 
to  them,  and  though  probably  even  their  present  eponymic 
and  euml)ersome  names  are  only  temporary,  and  will  be 
found  to  include  one  or  more  entities,  nevertheless  it  has 
already  become  more  profitable  to  deal  with  them  as  inde- 
pendent affections.  The  inconvenience  resulting  from  the 
present  use  of  the  term  "  splenic  anosmia  "  is  quickly  dem- 
onstrated to  anyone  making  a  critical  survey  of  the  litera- 
ture. Statistical  summaries,  including  valuable  detailed 
information,  are  thus  frequently  rendered  useless  when, 
on  analysis,  thoy  are  found  to  include  several  independent 
types  of  splenic  disease.  Cases  are  occasionally  reported 
under  such  headings  as  "  simple  hypertrophy  of  the 
spleen  "  or  "  idiopathic  splenomegaly,"  in  which  not  only 
has  annrmia  been  absent,  but  histological  examination  of 


TYPES  OF  SPLENOMEGALY 


243 


the  spleen  has  failed  to  reveal  any  peculiar  pathological 
change  ( Kidd,'^''*  Senator  and  Krause  **•* ) .  These  reports, 
however,  are  so  few  in  number  and  are  based  on  such  slight 
evidence  that  the  conditions  described  are  not  as  yet  entitled 
to  an  independent  consideration.  In  most  cases  names 
such  as  those  quoted  are  used  for  the  want  of  a  more  accu- 
rate designation,  a  practice  that  should  be  discouraged. 

Certain  other  diseases,  in  which  the  spleen  is  involved 
or  said  to  be  involved,  will  not  be  discussed  in  this  chapter. 
These  are  ( 1 )  various  ha?molytic  anspmias  of  specific  origin 
( dibothriocephalus  latus  and  uncinariasis),  (2)  lesions  of 
tlie  spleen  associated  with  thrombosis  of  the  portal  vein  or 
artery,  and  (3)  some  splenic  types  of  cirrhosis  of  the  liver. 
It  must  suffice  thereby  to  indicate  such  relations.  Also,  all 
types  of  enlarged  spleen  in  which  certain  features  render 
differentiation  easy  (as  leukaemia,  pseudoleuka?mia,  and 
changes  secondary'  to  obstruction  or  infection,  as  in  heart- 
disease,  typhoid,  kala-azar,  syphilis,  etc.)  will  be  omitted 
from  consideration.  This  leaves  the  more  definitely  dif- 
ferentiated offsprings  of  "  splenic  anfemia  "  as  Gaucher's 
disease  (or  large-celled  splenomegaly),  Banti's  disease,  v. 
Jaksch's  pseudoleuksemia  infantum,  the  Hayem-Widal  or 
acquired  form  of  ha;molytic  jaundice  with  splenomegaly, 
and  the  Chauffard-Minowski  or  congenital  or  familial  form 
of  the  same.  Some  of  the  differential  points  of  these  dis- 
eases are  indicated  in  Table  LXI. 


Gaucher's  Disease 

Gaucher's  disease,  or  large-celled  splenomegaly,  was 

probably  the  first  variety  to  be  differ'^ntiated  on  account 

of  its  peculiar  anatomical  picture.     Although  in  reality 

possessing  little  in  common  with  the  other  forms  of  splenic 


244 


o 
o 

Q 


THE  SPLEEN  AND  ANEMIA 


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TYPES  OF  SPLENOMEGALY 


245 


anfemia,  it  is  here  considered  in  some  detail,  on  account 
of  the  similarity  of  the  clinical  picture  and  from  the  fact 
that  it  is  still  included  by  many  writers  under  that  heading. 
Pathology. — First  described  by  Gaucher/''^  in  1882, 
as  a  primitive  epithelioma,  it  was  later  shown  not  to  possess 
most  of  the  characteristics  of  malignancy.  Bovaird  ''* 
called  it  a  simple  endothelial  hypcrjjlasia,  and  Brill  and 
Mandlebaum  '^  showed  that  the  cells  <leveloped  simultane- 
ously from  the  endothelium  of  the  spleen,  lymph-nodes, 
and  bone-marrow.  Diagnosis  during  life  is  not  easy,  but 
the  characteristic  large  vesicular  cells,  with  small  eccentric 
nuclei,  which  block  the  sinuses  of  the  spleen  and  lymph- 
nodes  or  are  crowded  about  the  liver  lobules,  render  the 
recognition  of  the  condition  a  simple  matter  to  the  pathol- 
ogist. A  careful  analysis  by  Brill  and  Mandlebaum  has 
reduced  the  number  of  authentic  reported  cases  to  four- 
teen. Since  that  time  cases  have  been  reported  by  Herr- 
mann,^'^  Knox,  Wahl  and  Schmeisser,'^'^  and  an  unpub- 
lished case  studied  by  Veeder,*^'  in  all  of  which  the  char- 
actenstic  vesicular  cells  were  found  in  the  spleen  and 
elsewhere.  JNIandlebaum  and  Downey,^'^  however,  reject 
Knox,  Wahl,  and  Schmeisser's  two  cases,  and  restrict  true 
Gaucher's  disease  to  those  cases  in  which  the  characteristic 
cells  are  arranged  either  in  enormously  enlarged  sinuses 
surrounded  by  thick  connective-tissue  walls,  or  as  solid 
masses  surrounded  by  connective  tissue.  They  consider 
that  cases  in  which  parenchymal  cells  (as  in  liver  and 
adrenal)  have  undergone  lipoid  (?)  change  should  not  be 
considered  as  ti*ue  Gaucher's  disease.  Knox,  Wahl,  and 
Schmeisser,  on  the  other  hand,  hold  that  "  any  disease  in 
which  the  spleen,  together  with  any  other  organ,  shows 
numerous  large,  pale  granules  or  finely  vacuolated  cells 


246 


THE  SPLEEN  AND  AN.EMIA 


giving  the  characteristic  microcheniical  reactions  for  lipoids 
and  showing  a  tendency  to  be  widely  distributed,  belongs  to 
this  (Gaucher)  group." 

An  acute  form  of  Gaucher's  disease,  with  fatal  termina- 
tion after  fifteen  months,  has  been  described  by  Niemann,^'* 
under  the  title  of  "  an  unknown  disease  picture."  The 
finding  of  characteristic  large,  endothelial-like  vesicular 
cells  at  autopsy  makes  it  probable  that  an  acute  form  of 
this  disease  nmst  also  be  recognized. 

Etigixxjy. — Its  etiologj'  is  still  in  doubt.  Malignancy, 
having  been  discredited,  various  theories  of  endogenous 
toxins,  splenic  enzymes,  or  of  infection  have  been  offered, 
but  none  is  supported  by  conclusive  evidence.  It  is  claimed 
that  a  similar  histological  picture  can  be  produced  in  ani- 
mals by  the  forced  feeding  of  cholesterin  ( McMeans,'''^ 
Luden'=«^). 

Symptomatology. — The  excellent  summary  of  Brill 
and  Mandlebaum  reveals  the  following  clinical  picture: 
The  disease  begins  insidiously  in  infancy  or  childhood 
(usually  l)efore  the  thirteenth  year)  and  pursues  a  very 
chronic  course  (average  of  twenty  years).  A  history  of 
similiar  trouble  in  the  family  is  frequently  elicited.  No 
great  disturbance  in  the  health  of  the  individual  occurs 
until  the  disease  has  persisted  for  some  time,  when  distinct 
anaemia  appears  and,  as  in  Banti's  disease,  a  definite  ten- 
dency to  submucous  or  subcuticular  hemorrhages.  These, 
however,  are  never  fatal,  and  death  usually  occurs  from 
jn  intercurrent  affection.  The  most  prominent  symptom 
is  the  progressive  enlargement  of  the  spleen,  which  may 
reach  greater  proportions  than  in  any  other  disease,  event- 
ually filling  most  of  the  abdomen.  The  abdominal  dis- 
comfort produced  by  the  enlarged  spleen  may  be  the  first 


TYPES  OF  SPLENOMEGALY 


247 


indication  of  the  disease.  As  in  Banti's  disease,  the  blood 
changes  are  not  very  characteristic.  The  anaemia  of  chlo- 
rotic  type  is  never  very  severe  (average  red  blood-cell 
count  of  advanced  cases  being  3,700,000).  A  definite 
leukopenia  is  usually  found,  though  the  differential  count 
remains  unchanged.  No  enlargement  of  the  superficial 
lymph-nodes  can  be  found,  and  jaundice  and  ascites  are 
rare. 

Liver  enlargement,  secondary  to  that  of  the  spleen, 
may  eventually  reach  considerable  proportions,  A  brown- 
ish discoloration  of  the  skin  has  l)een  noticed  with  a 
"  peculiar  yellowish,  wedge-shaped  thickening  of  the  con- 
junctivae, commonly  seen  on  both  sides  of  the  cornea?."  In 
spite  of  the  rather  negative  character  of  the  symptoms,  the 
disease  has  been  recognized  during  life  in  at  least  four  of 
the  seventeen  authentic  cases,  with  a  confirmation  of  the 
diagnosis  by  histological  examination  of  material  obtained 
by  splenic  puncture  or  after  splenectomy. 

Prognosis. — According  to  Herrmann,  Roth,  and  Bern- 
stein,*'* splenectomy  has  been  tried  in  nine  cases,  with 
three  deaths.*  This  probably  represents  too  high  a  mor- 
tality, but,  on  the  other  hand,  an  ultimate  cure  can  hardly 
be  expected  when  the  disease  is  known  to  exist  independ- 
ently in  the  bone-marrow,  lymph-nodes  and  elsewhere. 
Little  is  known  concerning  the  power  of  the  bone-marrow 
to  react.  The  resistance  of  the  red  cells  and  number  of 
skeined  cells  (as  evidence  of  power  of  blood  regeneration) 
have  not  been  studied,  but,  in  view  of  the  absence  of  signs 
of  increased  haemolysis,  one  would  not  expect  to  find  any 
noteworthy  changes  by  such  examinations.    On  the  other 

*  Vcedcr's  unpublished  case,  with  recovery  after  splenectomy,  in- 
creases these  figures  to  ten  cases  with  three  deaths. 


THE  SPLEEN  AND  AN.EMIA 

hand,  the  red  bone-marrow,  usually  present  at  autopsy, 
would  point  to  efforts  at  regeneration. 

To  sum  up,  this  disease,  despite  the  fact  that  it  is  fre- 
quently included  among  the  "  splenic  anfemias,"  has  but 
little  in  common  with  them  clinically  beyond  the  chroni- 
cally enlarged  spleen  and  anremia.  Pathological  examina- 
tion should  always  allow  the  proper  diagnosis  to  be  made. 

BaNTI's  D1SE.VSE 

Symptomatology. — Banti's  disease,  or  splenomegaly 
with  hepatic  cirrhosis,  was  first  described  by  Guido  Banti  ^'' 
in  1894,  and  the  clinical  picture  presented  at  that  time  still 
holds  although  the  etiology  and  pathogenesis  of  the  disease 
remain  in  almost  as  great  obscurity  as  at  the  time  of  its 
differentiation.     Usually  occurring  in  young,  otherwise 
healthy  adults  and  running  a  chronic  course,  its  sympto- 
matology may  l>e  divided  into  three  periods.     In  the  first 
or  pre-ascitic  period,  usually  lasting  several  years,  a  grad- 
ually increasing  weakness  and  pallor  is  noticed,  with  diges- 
tive disturbances  and  abdominal  pain,  which  may  first  call 
attention  to  the  enlarged,  smooth,  hard  spleen.     A  ten- 
dency to  hemorrhages  with  a  moderate  ana?mia  of  chlo- 
rotic  type  is  usually  present,  but  may  be  postponed  until 
the  later  stages.    There  is  nothing  specially  characteristic 
of  the  anannia,  the  mcrease  of  urobilin  being  the  most 
significant  sign  of  increased  blood  destruction.    The  resist- 
ance of  the  red  cells  is  unchanged ;  signs  of  a  regenerating 
bone-marrow,  as  nucleated  and  reticulated  red  cells,  are 
slight  or  absent.    After  splenectomy,  however,  an  increased 
resistance  of  the  cells  may  be  noted,  and  may  be  marked.* 

•  In  a  case  I  recently  examined  after  splenectomy  complete  ha»nio- 
lysis  did  not  occur  in  salt  solution  as  low  as  0.25  per  cent.  No  nucleated 
red  cells  were  found,  but  reticulated  forms  were  more  numerous  than 
before  splenectomy. 


<■*  \-^.. 


TYPES  OF  SPLENOMEGALY 


240 


A   slight    or   moderate   amount   of    leukopenia    is    char- 
acteristic. 

The  second,  or  intermediate,  stage  lasts  but  a  few 
months,  anr'  's  characterized  by  scanty,  high-colored  urine 
containing  ^  i  excess  of  urobilin,  by  attacks  of  dyspepsia 
and  diarrhoea,  and  by  slight  increase  in  the  size  of  the 
liver. 

The  third  stage  is  ushered  in  by  the  symptoms  of  cir- 
rhosis, a  recurrent,  -p -sinless  ascites,  occasionally  slight 
jaundice,  shrunken  live.,  and  increasing  ana?mia  and  ema- 
ciation. After  a  few  years  an  intercurrent  infection  or 
fatal  hemorrhage  is  the  terminal  event.  It  is  hardly  neces- 
sary to  say  that  such  a  picture  is  subject  to  variation, 
and  that  in  some  cases  the  three  periods  cannot  be  dis- 
tinguished. The  first  and  second  of  these  periods  are 
usually  considered  as  "  splenic  anaemia." 

Etiology  and  Pathogenesis. — In  spite  of  the  great 
amount  of  work  done  on  Banti's  disease  in  the  past  twenty 
years,  not  only  is  its  etiolog>'  undetermined,  but  it  is  still 
an  open  question  whether  it  is  a  disease  due  to  a  specific 
cause  or  is  merely  a  fairly  constant  symptom-complex, 
lianti  attempted  to  demonstrate  microorganisms  in  the 
blood  and  viscera  of  this  disease,  but  failed,  as  he  did  also 
in  his  various  attempts  to  reproduce  the  disease  in  lower 
animals.  He  insisted,  nevertheless,  that  the  splenic  en- 
largement was  primary  and  due  to  an  unknown  infectious 
agent  localized  in  the  spleen.  Recently  Gibson  '*'  has 
reported  the  finding  of  a  streptothrix  in  the  spleens  of 
certain  cases  resembling  Banti's  disease,  and  Yates,  Bunt- 
ing, and  Kristjanson  *"'  have  found  diphtheroid  organisms 
in  several  such  spleens.    As  these  findings  have  not  been 


f 


250 


THE  SPLEEN  AND  AN^ML\ 


confirmed,  however,  and  as  the  great  majority  of  investi- 
gators have  been  una'ile  to  isolate  a  causative  organism 
( Senator,* ""^  Sippy,*"*  Zancan,*"  etc.),  the  demonstration 
of  an  actual  ..ifecting  agent  must  be  considered  as  still 
lacking.  Suggestive  evidence,  however,  was  recently 
brought  forward  by  Hollins,'**  who  by  repeated  subcutane- 
ous injections  of  BaciUus  coli  was  able  to  produce  in  the 
rabbit  a  distinct  splenomegaly  with  moderately  severe 
anaemia  similar  to  that  of  Banti's  disease.  No  ha?molytic 
body  or  living  microorganisms  could,  however,  be  demon- 
strated at  autopsy.  Banti's  later  view  is  that  the  in- 
fectious agent  is  brought  to  the  artery  either  es  a  direct 
toxin  or  as  a  substance  which  is  changed  by  an  actual 
splenic  metabolism  into  a  splenotoxin.  The  earlier  changes 
are  therefore  to  be  found  in  the  neighborhood  of  the  fol- 
licular arteries,  and  later  in  the  pulp,  splenic  and  portal 
veins,  culminating  eventually  i  tlio  liver  changes  of  the 
third  stage.  The  symptoms,  according  to  Banti,  are  due 
to  general  toxa?mia,  and  the  anasmia  to  a  depression  of 
bone-marrow  activity  rather  than  to  excessive  haemolysis. 
As  the  degenerative  changes  in  the  spleen  are  too  far 
advanced  to  permic  conclusions  as  to  such  a  sequence  of 
events,  this  theory  has  never  been  confirmed  by  experiment 
or  obser\'!ition.  The  intimate  relationship  between  the 
spleen  and  liver  renders  intelligible  a  possible  pathologj' 
of  the  third  stage,  especially  as  Mallory'^^'  and,  later. 
Breccia '"'  have  shown  that  injurj'  to  the  spleen  is  followed 
by  focal  necroses  in  the  liver.  Banti  hi.s  objected  to  sug- 
gested etiological  relationship  c"  intestinal  disturbances, 
despite  the  many  cases  in  which  digestive  disturbances 
are  known  to  precede  or  usher  in  the  disease.     The  fact 


I'LATK  IV 


HiHtol"i»ry  oi  ■plt-en  ul  einly   B.u.ij'! 


tiiwJ**-' 


TYPES  OF  SPLENOMEGALY 


251 


that  the  spleen  is  involved  earlier  than  the  liver  would 
point  to  a  hasmatogenous  rather  than  an  enterogenous 
toxin,  and  the  unquestioned  improvement  that  usually  fol- 
lows splenectomy  indicates  that  the  altered  spleen  is  in  some 
way  fm  important  pathogenetic  factor.  This  is  still  fur- 
ther emphasized  by  Umber's*"  unique  observation.  A 
boy,  fifteen  years  of  age,  was  splenectomized  for  Banti's 
disease,  and  during  the  operation  a  small  piece  of  the  en- 
larged liver  was  excised  for  histological  examination  and 
a  distinct  peripheral  infiltration  of  the  lobules  found.  Later 
the  liver  returned  to  normal  size,  a  strong  indication  of  the 
splenogenous  origin  of  the  hepatitis,  which,  if  undisturbed, 
should  have  progressed  to  the  usual  cirrhosis. 

Trauma  to  the  spleen  has  been  offered  as  a  causative 
factor  in  some  cases  (Armstrong  ''*),  while  another  group 
of  authorities  consider  Banti's  disease  merely  a  syndrome, 
which  a  great  variety  of  causes  are  capable  of  producing 
(Albu,»  Isaac^"''  Luce,""  Neuberg,''"  Seiler  *"=').  There 
is  no  question  that  various  conditions,  as  an  atypical  cir- 
rhosis of  the  liver  with  early  prominence  of  splenic  signs, 
syphilis,  or  primary  endophleliitis  or  thrombosis  of  the 
splenic  or  portal  vein  can  produce  a  picture  which  cannot 
be  distinguished  from  that  of  Banti's  disease  (Edens,'**^ 
Goldman  *" ) .  As  endophlebitis  or  thrombosis  is  a  fre- 
quent accompaniment  of  true  Banti's  disease,  it  is  but 
natural  that  the  symptomatolog>'  of  the  two  conditions 
should  he  confounded,  Banti  himself  called  attention  to 
the  frequency  of  these  changes  in  his  original  descriptions, 
but  considered  the  splenic  changes  primary.  Other  authors 
consider  that  when  the  endophlebitis  or  thrombosis  is  pri- 
mary' certain  chai  acteristic  sjTnptoms  will  often  point 
toward  a  proper  differential  diagnosis,     Warthin  *'^^  in- 


WhBM 


252 


THE  SPLEEN  AND  ANzEMlA 


f 


sists  that  an  infectious  thrombophlebitis  of  the  portal  or 
splenic  ve.n  is  the  essential  feature  of  the  syinptoni-coni- 
plex,  whereas  the  upholders  of  the  separate-entity  theory 
claim  that  such  changes  are  secondary  to  the  changes  in  the 
spleen  or  may  be  absent  altogether  (Ziegler  "« )  In  eer 
tam  cases  of  syphilis  of  the  liver,  also,  the  splenomegaly, 
T'TT'  ^""^  ^''*°'-'  "^  h^matemesis  may  be  so  prominent 
( Osier -fj'*"'^  ""^  ^^""^''  '^'''^''  ''  ^^^y  '^""''^y  ^^"^^t^ 

When  a  consideration  of  the  above  featTires  allows  a 
differentiation  to  be  attempted  it  would  seem  advisable 
to  consider  such  cases  as  pseudo-Banti's  disease,  and  to 
restrict  the  u.se  of  the  term  true  Banti's  disease  for  those 
eases  in  which  no  such  etiological  factor  is  ajjparent 

The  nature  of  the  splenic  enlargement  has  also  ifiven 
rise  to  several  hypotheses.    The  view  that  it  is  spodoge.ious 
can  be  ruled  out,  on  account  of  the  absence  of  histological 
evidence  to  support  it,  and  Barr's  '«  theon^  of  splenio  con- 
gestion due  to  splanchnic  vasomotor  paresis  needs  merely 
to  ne  mentioned.    The  prevailing  opinion  is  that  the  en- 
largement is  due  to  a  chrunic  inflanmiatory  process,  which 
m  turn  results  in  an  increased  functional  activity   (in- 
creased  ha-molysis),  with  a  resultant  anaemia.     Thi's  view 
IS  m  accord  with  Botazzi's  ha>mocatatonistic  and  Banti's 
ha^molytic  theories.     Ha'molysis  is  considered  by  Harris 
and  ITerzog  to  be  due  to  an  eiythrolytic  enzyme  elab- 
orated by  the  hyperplastic  endothelial  cells,  and  by  Lint- 
varew  to  an  increase  in  the  erythropl.agic  action  of  the 
sp.een-cells.  the  resultant  fibrosis  being  due  to  the  chronic 
irritation  of  the  products  of  red-cell  destruction.     The 
absence  in  the  circulating  blo^xl  of  signs  of  bone-marrow 


m 


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TYPES  OF  SPLENOMEG.\LY 


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activity  points,  however,  to  a  diminished  activity  in  blood 
Connation,  but  against  this  is  the  increased  urobilin  elimina- 
tion as  evidence  of  increased  blood  destruction.  The 
probable  existence  of  a  splenic  hormone  to  the  bone-marrow 
and  its  disappearance  in  splenic  disease  can  be  invoked  to 
explain  the  greater  anaemia  when  the  splenic  tissue  has  been 
largely  replaced  by  fibrosis;  but,  on  the  other  hand,  the 
improvement  in  the  blood  picture  that  follows  splenectomy 
suggests  the  removal  of  a  pernicious  hasmolytic  activity  on 
the  part  of  the  spleen. 

Pathology. — In  the  pathological  histology  of  the  dis- 
ease there  is  nothing  specially  distinctive.  The  enlarged 
spleen,  as  a  lule,  shows  an  int -eased  amount  of  fibrous 
tissue  in  the  capsule  and  reticulum,  usually  characterized 
as  "  fibroadenie  "  (that  is,  iiicreased  fibrous  tissue,  but  re- 
taining an  adenoid  appearance),  and  involving  both  pulp 
and  follicles.  The  Malpighian  follicles,  especially  in  the 
later  stages,  are  small  and  scarce;  in  the  earlier  stages  they 
may  be  hyperplastic  and  the  "  fibroadonie "  be  absent. 
Macrophages,  increased  amount  of  pigment,  and  other 
evidences  of  increased  blood  destruction  are  usually  found. 
The  changes  in  the  liver  are  those  of  an  ordinary  periportal 
cirrhosis. 

In  summarizing,  one  might  say  that,  although  the  eti- 
ologj'  of  true  Banti's  disease  is  unknown  and  may  well  be 
from  several  sources,  evidence  points  to  the  close  causative 
relationship  of  the  spleen.  One  would  not  expect  the  re- 
moval of  a  largely  fibrotic  organ  to  be  attended  with 
marked  somatic  changes,  and  it  is  precisely  in  the  earlier 
stages  of  the  disease  in  which  splenectomy  has  proved 
most  beneficial. 


■*r'<i^<0i^-i^- 


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.f^:-^j^W§^^j!^r9^-  .^-_^i!^<^.;z^^^^^s^^;^^j;;j^^s^^ 


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THE  SPLEEN  AND  ANEMIA 


ft       >       I 


Von  Jaksch's  Disease 
The    anaemia    infantum    pseudoleukaemica    of    von 
Jaksch  '"*»  is  in  all  probability  not  an  independent  condi- 
tion, but  represents  an  atypical  response  of  the  infantile 
ha'mopoietic  system  to  one  or  other  of  the  primary  dis- 
eases  of  the   blocxl    (leuka'mia,   pernicious   ana-mia,   the 
secondar>'  anannia  of  rickets,  syphilis,  Banti's  disease,  or 
the  formerly  unrecoprnized  types  of  hjvmolytic  jaundice). 
As  a  rule,  a  hitjh-^rade  ana-mia,  with  blood  picture  some- 
what resemblinn-  pernicious  ana-mia,  appears  in  infants 
of  one  or  two  years.    Leucwytosis,  especially  of  the  small 
lymphocytes,  is  a  frequent  response  to  any  form  of  aniemia 
in  infancy  and  childhood.    The  smooth,  hard  spleen  is  con- 
spicuously lar^e,  while  the  liver,  in  contrast  to  the  liver  of 
leukaemia  in  childhood,  is  very  slifrhtly  enlarged.    Aschen- 
heim  and  Benjamin  "*  have  found  rickets  present  in  all 
of  a  series  of  such  cases  examined  by  them,  and  suggest 
the  name  "  Rachitische  :Megalosplenie  "  for  this  condition. 
Von  Jaksch   also   associated   rickets   with   this   disease. 
Giffin'^*  and  others,  on  the  other  hand,  consider  the  true 
v.  Jaksch's  disease  to  be  nothing  more  than  the  infantile 
form  of  splenic  ana?mia.     (Banti's  disease.)      That  von 
Jaksch's  disease  is  being  less  and  less  regarded  as  a  sepa- 
rate disease  is  shown  by  the  gradual  disappearance  of  the 
name  from  the  text-books. 

H.-EMOLYTic  Jaundice 
The  acquired,  Hayem-Widal,  and  congenital  or  famil- 
ial, Chaufi'ard-^Minkowski  types  of  ha^molytic  jaundice 
with  splenomegaly  are  frequently  grouped  by  English  and 
American  authors  under  such  titles  as  "  ha?molytic  jaun- 
dice "     (Thayer '"'),    and    "chronic    family    jaundice" 


TYPES  OF  SPLENOMEGALY 


(Tileston*''").  As  the  two  forms  possess  several  rather 
important  and  characteristic  differences,  it  is  deemed  ad- 
visable to  follow  the  continental  custom  and  consider  them 
a!>  independent  conditions.  Search  for  their  true  etiology 
and  pathogenesis  (as  yet  unknown)  is  more  apt  to  be 
stinmlated  under  such  an  arrangement  than  if  they  are 
grouped  together.  Furthermore,  Widal,  Abrami,  and 
IJrule*^"  experimenting  with  toluylenediamine.have  offered 
evidence  to  indicate,  in  their  opinion,  that  the  two  types  are 
of  different  origin. 

Symptomatology. — The  points  of  differentiation  we 
will  present  after  outlining  the  historical  development  of 
our  general  knowledge  of  ha-molytic  jaundice.  Although 
iMurchison,^***  Wilson,^'^  and  others  had  previously  de- 
scribed cases  of  chronic  jaundice  (x^curring  in  several  mem- 
bers of  a  family  (in  Murchison's  case  splenomegaly  is  not 
mentioned),  it  was  the  more  complete  description  of 
Hayem,"^  in  1898,  that  first  established  the  condition  as  a 
clinical  entity.  The  clinical  picture  of  the  five  cases  ana- 
lyzed by  him  was  as  follows:  All  five  exhibited  a  chronic 
jaundice,  with  the  presence  of  bile-pigment  in  the  blood- 
serum,  but  not  in  the  urine  {i.e.,  acholuric  icterus).  The 
other  signs  of  obstructive  jaundice,  such  as  itching,  brady- 
cardia, and  clay-colored  stools,  were  also  lacking.  A  dis- 
tinct anaemia,  the  red-cell  count  varying  from  1,000,000  to 
3,000,000,  was  present  in  all.  Very  large,  hard  spleens 
were  found  in  each  case,  and  slight  enlargement  of  the  liver 
was  also  noted.  Exacerbations  were  frequent,  and  during 
these  the  jaundice  deepened  and  bile  appeared  in  the  urine. 
The  importance  of  these  exacerbations  was  emphasized  by 
Widal,  who  termed  them  "  crises  of  deglobulization."  and 
considered  them  highly  characteristic  of  the  acquired  form. 


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THE  SPLEEN  ANT>  AN^.MIA 


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In  severe  cases  the  blood  count  fell  below  1,000,000  and 
haemoglobin  appeared  in  the  urine.  In  all  five  of  Ilayem's 
cases  the  family  history  was  negative,  and  in  three  the  jaun- 
dice was  stated  to  have  appeared  first  in  adult  life. 

Two  years  later  Minkowski  ='"  described  a  similar  dis- 
ease occurring  during  three  generations  in  eight  members 
"  one  family.  This,  tlie  congenital  form,  it  is  now 
known,  is  commoner  than  the  acquired  form.  In  addition 
to  tlie  symptoms  presented  by  Hayem's  cases,  an  increased 
amount  of  urobilin  was  noted  in  the  urine.  Autopsy  re- 
vealed no  cirrhosis  of  the  liver  or  obstruction  of  the  bile- 
passages.  The  spleen  showed  a  diffuse  hyperplasia  and 
hypera-mia.  Pigment  deposits  were  numerous  in  the  kid- 
neys and  in  the  centres  of  the  liver  lobules. 

The  next  important  contribution  to  the  clinical  pic- 
ture of  these  diseases  was  made  by  ChaufTard,"  who  showed 
in  the  congenital  type  that  tlie  resistance  of  the  red  blood- 
cells  to  hypotonic  salt  solution  was  much  diminished. 

Increased  numbe.-  of  microcytes  and  of  reticulated  red 
cells  by  methods  of  vital  staining  were  found  by  Chauf- 
fard  "2  in  the  congenital  or  familial  type,  and  their  presence 
later  confirmed  also  in  the  acquired  type. 

Another  diagnostic  method,  the  auto-agglutination 
test,  is  advocated  by  Widal,  Abrami,  and  Brule."'*  They 
have  found  it  always  positive  in  the  acquired  form  and 
always  negative  in  the  congenital  or  familial  type.  How- 
ever, in  Micheli's^'*^  carefully  studied  case  of  the  acquired 
type  this  test  was  also  negative.  Isoh^molysins  have  occa- 
sionally been  found  in  both  types  (Micheli,^"  Hopkins  '«*) , 
but  are  not  supposed  to  possess  any  pathological  signifl- 
cance.    Although  both  types  of  hemolytic  j  „undice  usually 


TYPES  OF  SPLENOMEG.VLY 


257 


run  a  chronic  course,  Gaisbock  ""  has  shown  that  an  acute 
uiahgnant  form  may  occur  that  is  fatal  in  a  few  montlis. 

Therefore  the  cardinal  symptoms  of  the  two  types  of 
haimolytic  jaundice  with  splenomegaly  are  found  to  be  a 
chronic  enlargement  of  the  spleen,  existing  with  an  acho- 
luric, non-obstructive  jaundice,  and  anaemia,  frequently 
paroxysmal  in  character  and  varj'ing  in  intensity.  In- 
creased blood  destruction  is  indicated  by  increased  urobilin 
in  the  urine,  and  various  characteristic  changes  are  found 
in  the  blood.  The  red  cells  show  diminished  resistance  to 
hypotonic  salt  solution,  increased  number  of  reticulated 
cells  with  vital  staining,  and  in  the  acquired  form  the 
jihenomenon  of  auto-agglutination  of  the  red  corpuscles. 
The  blood-serum  rarely  contains  auto-  or  isobemolysins. 

We  have  purposely  postponed  until  now  a  considera- 
tion of  the  differentiation  of  the  acquired  and  familial 
types  and  their  relation  to  other  conditions,  such  as  those 
suggested  by  Gilbert  "»  and  Eanti."'  The  fact  that  in  the 
actpiired  group  the  disease  is  definitely  acquired  in  adult 
life,  whereas  in  the  other  there  is  a  family  history  of  the 
same  trouble,  is  not  in  itself  sufficient  to  warrant  the  dis- 
tinction of  independent  disease  pictures.  There  are,  how- 
ever, other  features  which  tend  to  differentiate  the  two 
types.  In  the  congenital  form  the  subjects,  as  Chauffard 
puts  it,  "are  more  icteric  than  sick."  Frequently  they 
come  for  treatment  for  other  conditions  and  consider  the 
chronic  jaundice  as  a  family  idiosjTicrasy  not  interfering 
with  perfect  health.  The  acquired  form,  on  the  other  hand, 
is  usually  ushered  in  with  a  definite  attack  of  illness;  the 
anemia  becomes  much  more  grave,  sometimes  as  low  as 
1 .000.000.  and  the  patient  is  distinctly  more  ana'mic  than 
jaundiced.  In  Decastello's  "  case,  which  was  greatly  im- 
17 


258 


THE  SPLEEN  AND  AN/EMIA 


:i 


proved  by  splenectomy,  the  red-cell  count  had  previously 
fallen  to  800,000. 

An  analysis  of  159  cases  of  hsemoly tic  jaundice  in  which 
blood  counts  are  available  shows  that  55  belong  to  the 
acquired  type  and  104  to  the  congenital  or  familial  type. 
Of  the  latter,  only  23  failed  to  give  a  positive  family  his- 
tory; but  pf  the  81  remaining  cases  the  disease  in  36  de- 
veloped after  birth.  The  term  "  familial "  would  there- 
fore seem,  preferable  to  that  of  "  congenital,"  unless  a  third 
variety  is  to  be  considered.  The  average  red-cell  count  of 
the  55  acquired  cases  is  2,032,000,  the  counts  ranging  from 
510,000  to  4,500,000.  Counts  belov  1,000,000  are  recorded 
in  ten  cases;  below  2,000,000  in  27  cases,  and  over  4,000,- 
000  in  only  four  cases.  The  average  count  of  the  103, 
congenital  and  familial,  is  3,340,000,  the  counts  ranging 
from  1,800,000  to  5,700,000.*  Xo  counts  are  recorded 
below  1,000,000 ;  eight  below  2,000,000,  and  25  above  4,000,- 
000.  If  this  group  is  subdivided,  the  average  of  the 
familial  cases  is  3,281,000;  of  the  congenital,  3,543,000. 
These  figures  show  that  there  is  a  more  marked  ansmia 
in  the  cases  of  the  acquired  type  than  in  either  the  familial 
or  congenital  types. 

Widal  and  his  pupils  claiiri  that  the  auto-agglutination 
test  is  only  positive  in  the  acquired  form,  and  consider  this 
as  important  evidence  that  the  two  diseases  have  funda- 
mentally different  origins.  Attention  has  already  been 
called  to  the  differential  importance  of  Widal's  "  crises  of 
deglobulization,"  but  it  must  be  admitted    that  marked 

*  One  familial  case  reported  by  v.  Krannhals  showed  1,000,000 
red  cells  in  a  single  count,  but,  as  the  haemoglobin  was  between  55  and 
65  per  cent.,  the  accuracy  of  the  count  is  questionable. 


T\TES  OF  SPLENOMEGALY 


259 


fluctuations  in  the  degree  of  blood  destrnction  are  present 
also  in  the  familial  type. 

Numerous  reports  are  at  hand  of  a  condition  apparently 
identical  with  the  acquired  form,  but  following  attacks  of 
malaria,  syphilis,  and  other  infections.  In  such  cases  the 
signs  of  excessive  blood  destruction  usually  disappear  when 
the  underlying  cause  is  successfully  treated.  The  familial 
form,  on  the  other  hand,  appears  more  as  an  inherited 
dystrophy  of  the  ha^mopoietic  system,  rendering  the  red 
blood-cells  more  easily  destructible.  On  this  basis  Chauf- 
fard  at  first  strongly  advised  against  splenectomy  in  this 
type,  but  subsequently  cases  have  shown  such  improve- 
ment after  this  treatment  that  it  would  seem  as  if  the 
removal  of  this  site  of  blood  destruction  was  advisable, 
whether  or  not  it  is  the  primarj-^  seat  of  the  trouble.  It 
nmst  be  noted,  however,  that  after  Kahn's  =""  and  Roth's  '**" 
successful  splenectomies  in  the  familial  type  the  resistance 
of  the  red  cells  failed  to  return  to  normal.  The  congenital 
type  with  negative  family  historj',  grouped  with  the  familial 
type  by  most  authors,  offers  no  definite  ground  for  differ- 
entiation from  the  acquired  form.  The  mere  fact  that  the 
disease  has  already  made  its  appearance  at  birth  is  of  it- 
self not  of  fundamental  importance  if  there  is  no  history 
of  similar  trouble  in  the  family.  If  the  familial  form 
(which,  as  a  matter  of  fact,  is  usually,  though  not  always, 
congenital)  were  placed  in  contrast  to  the  acquired  form, 
the  time  of  onset,  as  indicated  by  the  term  congenital, 
might  well  be  disregarded.  The  possibility  of  an  early 
acquisition  of  the  disease  is  shown  in  the  case  reported  by 
Benech  and  Sabrazes.**  With  a  negative  family  history, 
a  suckling  is  su])posed  to  have  accjuired  the  disease  from 
her  wet-nurse,  who,  together  with  her  two  children,  had 


soo 


THE  SPLEEN  AND  AN/EMLV 


1       'i  n 


a  chronic  hfcniolytic  jaundice.  Certain  authors  consider 
the  acquired  and  congenital  types  as  identical.  Hynek,"*' 
for  instance,  bases  his  opinion  on  two  cases  observed  by 
him:  in  one  a  mother  acquired  the  disease  after  childbirth, 
whereas  in  her  child  it  appeared  congenitally.  Plehn^'^* 
reports  a  case  appearing  congenitally  in  father  and  daugh- 
ter, but  not  until  the  twenty-sixth  year  in  the  case  of  a 
son.  Benjamin  and  Sluka '-  obser\-ed  three  cases  in  one 
family,  two  appearing  congenitally  and  one  in  adult  life. 
Many  of  these  cases  could  undoubtedly  be  harmonized  if 
the  time  of  onset  were  disregarded. 

In  favor  of  the  identity  of  the  two  types  (acquired 
and  congenital)  it  must  be  admitted  that  a  series  of  cases 
could  be  selected  in  which  many  grades  l)etween  the  two 
types  would  be  represented.  It  is  obvious  that  the  familial 
type  must  at  one  time  or  another  have  originally  been 
acquired.  In  such  an  event  the  difFerence  in  severity  be- 
tween the  acquired  and  familial  still  holds.  Thus  both  in 
Roth's  •''**''  and  Bychowski's  «*  cases  tiie  disease  in  the  parent 
who  acquired  it  was  severe,  while  in  the  children  who  in- 
herited it  it  was  of  the  usual  mild  type.  Such  facts,  how- 
ever, would  not  indicate  a  fundamental  difference  in  the 
nature  of  the  two  diseases. 

In  the  small  numl)er  of  cases  already  accumulated  vari- 
ous atypicalities  have  l)een  reported.  Thus,  Lommel's  "- 
and  Claus  and  Kalberlah's  '"  cases  of  the  familial  type  and 
Mosse's  ^"*  and  Tixier's  *''°  cases  of  the  acquired  type  failed 
to  show  any  change  in  resistance  of  the  red  ceils  (either 
washed  or  tlie  whole  blood),  though  other  evidences  of 
increased  blood  destruction  were  present.  In  a  few  cases 
an  acholuric  j.iundice  with  splenomegaly  has  existed  to- 
gether with  polychytha'mia  instead  of  anemia.  Chauffard 


TYPES  OF  SPLENOMEGALY 


261 


and  Vincent""  and  Roth  ^*'  have  rece»itly  described  a 
form  in  which  hemolysins  are  present  in  the  blood,  and  such 
cases  appear  to  occupy  a  position  midway  between  htemo- 
lytic  jaundice  and  paroxysmal  ha>nio<Tlobinuria  "  a  fri- 
gore."  Gilbert  '^^  and  his  pupils  have  published  numerous 
reports  since  1900  on  similar  conditions  under  the  name 
of  "  cholemie  familiale."  They  have  at  least  served  to 
call  attention  to  the  fact  that  variations  may  be  found  in 
the  amount  of  enlargement  of  the  spleen  and  liver.  It  is 
(juestionable,  however,  if  it  is  necessarj^  as  they  have  fre- 
(|uently  done,  to  consider  each  atypical  form  as  a  separate 
condition  to  l>e  dignified  with  a  separate  name.  As  many 
of  their  cases  were  described  before  the  various  hasmato- 
logical  methods  above  described  had  come  into  vogue,  and 
are  frequently  reported  in  resume,  it  is  difficult  to  deter- 
mine conclusively  whether  or  not  they  should  be  considered 
as  l)elonging  to  the  types  under  discussion.  Their  theory 
of  hepatic  origin,  thi-ough  an  infectious  angiocholitis,  they 
later  abandoned  in  favor  of  ChaufFard's  idea  that  the  pri- 
mary change  was  in  the  blood. 

Another  occasional  variation  is  in  the  presence  of  all 
symptoms  of  increased  blood  destruction  but  an  absence 
of  icterus.  This  Chauffard  describes  in  a  family  in  which 
the  mother  is  a  typical  ha;molytic  icteric,  while  the  eighteen- 
year-old  son  presents  all  the  signs  of  the  disease  except 
jaundice. 

When  the  anaemia  is  grave  the  blood  may  present  a 
picture  indistinguishable  from  pernicious  anaemia  (v. 
Stejskal  *'") .  Chauftard  considers  that  there  is  an  icteric 
form  of  pernicious  ansemia  which,  when  accompanied  by 
diminished  resistance  and  reticulated  red  cells,  represents 
the  least  compensated  form  cf  haemolytic  icterus.   Widal 


262 


THE  SPLEEN  AND  ANEMIA 


:ii 


a     It 


and  Weissenbach  *"'  have  also  reported  a  case  of  this  type. 
In  the  usual  Biernier  type  of  pernicious  ana?mia,  icterus, 
it  will  he  recalled,  is  absent  and  the  resistance  of  the  red 
cells  increased. 

Banti  ^-  has  recently  proposed  the  name  "  haemolytic 
splenomegaly  "  for  a  type  of  the  disease  which  on  analysis 
is  indistinguishable  from  the  acquired  form  of  hemolytic 
jaundice.  Both  the  cases  described  by  him  exhibit  a 
chronic  ana'mia,  with  long-standing  splenomegaly,  subic- 
terus,  diminished  resistance  of  the  red  cells,  increased  nimi- 
ber  of  reticulated  cells,  and  urobilinuria.  In  a  later  study  ^^ 
of  seven  cases  of  this  condition  he  further  subdivides 
"  ha?molytic  splenomegaly  "  into  regenerative  and  degen- 
erative groups,  the  difference  depending  chiefly  on  periods 
of  relapse  and  remission  in  the  former  type,  with  greater 
evidences  of  regeneration  in  the  blood  picture.  The  bene- 
ficial effects  of  splenectomy — abolishing  the  anjcmia  and 
changing  the  resistance  to  normal  in  one  case  and  even 
changing  an  aplastic  into  a  reacting  bone-marrow — lead 
him  to  ascribe  a  primary  role  in  this  disease  to  the  spleen. 
It  must  be  remembered,  of  course,  that  removal  of  the 
normal  spleen  indirectly  causes  an  increase  in  resistance 
of  the  red  cells.  Banti  claims  never  to  have  see  i  Widal's 
crises  of  deglobulization  in  these  patients,  and  emphasizes 
the  presence  of  a  relative  lymphoc\i;osis,  but  this  would 
hardly  indicate  a  different  disease.  As  to  the  choice  of 
name,  Banti's  name  is  open  to  the  same  objection  as  the 
older  one;  namely,  that  splenomegaly  may  be  absent  in 
some  cases  (Le  Gendre,^^''  Pick,''"  Gilbert  and  Lereboul- 
let,""^  Benjamin  and  Sluka's  third  case,  and  Marchiafava 
and  Nazzari,^")  just  as  jaundice  is  in  others.  A  name 
indicating  increased  blood  destruction,  such  as  "  ha;mo- 


TYPES  OF  SPLENOMEGALY 


263 


lytic  Hypersplenism,"  without  including  individual  fea- 
tures, would  he  less  open  to  objection;  but  in  the  mean- 
time, until  hypersplenism  can  be  demonstrated,  the  name 
sanctioned  by  usage  is  preferable. 

Pathogenesis. — As  I  have  already  indicated  in  the 
discussion  of  the  differentiation  of  the  two  types,  a  hepatic 
or  luetic  etiology  has  been  largely  discarded.  Such  etiology 
is,  however,  still  occasionally  reported  (Bernard,  de  Beru- 
iiiann,  Gelle),  as  is  also  that  of  malaria  (Socquepee)  and 
ankylostomiasis  (Darre,  Parisot,  and  Fairise).  The  two 
prominent  views,  however,  are  ( 1 )  that  the  primary  lesion 
is  in  the  blood — a  dystrophy  of  the  red  cells;  or  (2)  either 
primarily  or  indirectly  in  the  spleen — an  exaggerated 
hsemolytic  a/jtivity.  Widal  and  his  school,  the  extreme 
supporters  of  the  former  view,  consider  that  the  congeni- 
tally  weak  red  blood-cells  are  destroyed  in  the  circulation 
and  their  remains  taken  up  by  the  spleen,  causing  a  spo- 
(logenous  tmnor,  and  by  the  liver,  kidney,  and  bone-mar- 
row, as  shown  by  the  excessive  pigment  deposits  found  in 
these  organs  at  autopsy.  This  view  was  supported  by 
Vaquez,*""  von  Stejakal,  Benjamin  and  Sluka,  Aschen- 
heim,"  and  Weber  and  Dorner.^"^  The  chief  objection  to 
it  is  that  it  completely  ignores  the  great  improvement  fol- 
lowing splenectomy.  A  primary  increased  hemolytic 
activity  of  the  spleen  as  the  source  of  the  malady  was  first 
proposed  by  Minkowski  and  supported  by  von  Krannhals 
and  ChaufFard.  Its  latest  adherent,  Banti,  as  I  have  pre- 
viously stated,  considers  that  the  pathological  spleen  not 
only  is  spodogenous,  but  actively  destroys  increased  num- 
l)ers  of  cells  and  prepares  others  for  destruction.  Though 
based  on  incorrect  and  inadequate  experimental  evidence, 
tliis  attractive  combination  of  the  splenogenous  and  haemo 


264 


niE  SPLEEN  AND  AN.EMU 


catatonistic  theories  at  present  seems  most  plausible. 
Although  it  is  not  possible  to  demonstrate  ha?molysis  in  the 
normal  spleen,  we  cannot  exclude  the  poss'bility  that  it 
exists  and  that  it  is  active  in  some  diseased  conditions  of 
the  organ.  Extracts  from  the  spleens  of  Antonelli's,' 
Kahn"sr°«  and  Robertson's ''"'•  cases,  however,  failed  to 
show  any  ha'molytic  activity  in  vitro. 

Whatever  the  source  of  the  increased  blood  destruction, 
there  results  an  increased  amount  of  free  hemoglobin  to 
be  gotten  rid  of.      Most  authorities  believe  that  this  is 
changed  by  the  liver  into  bile  in  excessive  amounts,  and 
that  the  viscid  and  highly  pigmented  bile  clogs  the  bile- 
capillaries,  is  reabsorbed  into  the  blood,  and  thus  causes  a 
"  pleiochromic  icterus."     Recent  investigations  by  Whip- 
ple,^««  however,  show  that  bilirubin  can  be  formed  by 
the  action  of  the  endothelium  of  blood-vessels  entirely  iso- 
lated from  the  hepatic  circulation.     If  this  be  true,  a 
hematogenous  icterus  in  the  narrower  sense  can  be  ac- 
cepted.   That  the  jaundice  is  not  due  to  gross  obstruction 
is  proved  by  the  facts  that  such  obstruction  has  never  been 
found,  that  the  stools  are  of  normal  color,  and  that  the 
urine  does  not  contain  bilirubin. 

It  is  interesting  to  note  that  in  Banti's  aplastic  or 
anamopoietic  case  splenectomy  started  the  formative 
powers  of  the  bone-marrow,  as  shown  by  the  appearance 
of  normoblasts  in  the  circulating  blood.  This  would  indi- 
cate that  with  the  spleen  was  removed  a  toxin  that  had 
inhibited  blood  formation,  and  from  this  it  could  be  argued 
that  the  decreased  resistance  of  the  red  cells  of  hemolytic 
jaundice  is  due,  not  to  a  hemocatatonistic  action  of  the 
spleen,  but  to  an  indirect  injury  to  the  bone-marrow. 

Pathological  study  of  the  comparatively  few  cases  of 


-  - :..! 


I'l  \ii'  \ll 


1  |UKi>u-nt. 


1; 

. 

'» 

1 

1  ■: 

:•? 

T\TES  OF  SPLENOMEC  \T.Y 


hit 


hiTHJolytic  jaundice  thnt  have  onme  [o  autopsy  or  sple- 
nectomy has  yiehled  httle  in  the  way  of  establishing  a  con 
stiuit  and  characteristic  pathological  picture.  I  have  col- 
lected descriptions  of  seven  spleens  obtained  at  autopsy 
and  of  eight  obtained  after  splenectomy.  An  analysis  of 
these  appears  in  Table  LXII. 

It  will  be  seen  that  the  chief  characteristic  of  both  types 
of  the  disease  is  the  marked  congestion  of  the  splenic  pulp 
and  splenic  sinuses,  hut  this  is,  of  course,  found  in  many 
other  conditions.  The  Malpighian  follicles,  the  capsule, 
and  trabeculae  are  frequently  left  unchanged;  and,  while 
pigment  deposits  and  macrophages  have  usually  been 
found  to  be  increased,  in  the  case  reported  from  this  labora- 
tory this  was  not  found  to  be  true.  In  all  cases  in  which 
the  bone-marrow  was  examined  at  autopsy  it  was  found 
to  be  red. 

Pernicious  Anaemia 

This  disease  is  mentioned  briefly  here,  not  as  an  ex- 
ample of  splenomegaly,  but  because  the  recent  tendency 
to  treat  it  by  splenectomy  brings  it  into  relation  with  the 
theory  of  hypersplenism.*  This  latter  theory  has  been  put 
forth  prominently  in  recent  years  by  Eppinger*"*  and 
King,^"  who  consider  that  the  amount  of  haemolysis  in  a 
given  case  is  in  definite  relation  to  the  amount  of  unsatu- 
rated fatty  acids  and  the  amount  of  urobilin  in  the  faeces. 
They  found  both  these  increased  not  only  in  Hsemolj'tic 
jaundice,  but  also  in  pernicious  anaemia,  hypertrophic  cir- 
rhosis, and  catarrhal  jaundice.  For  example,  the  unsatu- 
rated fatty  acids,  as  may  be  seen  in  Table  LXIII,  rise 
from  a  normal  (iodine  number)  of  80  or  90  to  188  to  273 

*  For  iummary  of  recent  literature  on  this  subject  see  Vogel.*" 


i{ 


266 


THE  SPLEEN  AND  ANAEMIA 


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TYPES  OF  SPLENOMEGALY 


267 


in  pernicious  anaemia.  As  they  had  found  experimentally 
that  removal  of  the  spleen  in  the  dog  caused  a  great  drop 
in  the  iodine  number  and  was  associated  with  an  increased 
resistance  of  the  red  cells  and  lessened  tendency  to  haemo- 
lysis, they  favor  splenectomy  in  this  type  of  ansmia. 
Eppinger's  theory  of  the  pathogenesis  of  pernicious  anae- 
mia is  interesting,  but  not  convincing.     On  histological 

TABLE  LXIII 

Analysis  of  Blood  Fat  in  An«mta  and  Other  Conditions  •   (Modified 
FROM  Table  of  Eppinoer  "^  and  Ki.nu"'J 


Total 
fat 
gms. 


Choles- 

terin 
gms. 


Normal 

Normal 

Pernicious  autemia 

Pernicious  anaemia 

Pernicious  ansemia 

H£emolytic  jaundice 

Ha;molytic  jaundice 

Cirrhosis  of  liver 

Cirrhosis  of  liver 

Cirrhosis  of  liver 

Catarrhal  jaundice 

Catarrhal  jaundice 

Catarrhal  jaundice 

Obstructive  jaundice 

Obstructive  jaundice 

Secondary  ana!mia,  carcinomatous  stomach  . 
Secondary  antemia,  carcinomatous  a-sophagus 

Nephritis 

Nephritis 

Polycytha-mia 

Purpura 


5.38 
5.90 
7.34 
8.40 
9.37 
5.43 
6.33 
9.01 
3.94 
7.36 
5.70 
5.40 
5.60 

10.63 
7.92 
6.39 
6.97 
8.24 

15.89 
6.93 
8.50 


0.76 
0.86 
0.56 
0.32 
0.14 
0.49 

y.s5 

0.91 
0.30 
0.56 
0.50 
0.39 
0.48 
1.07 
0.61 
0.71 
0.38 
0.56 
1.26 
1.09 
0.86 


Choles- 
terin 
eater 
gm. 


0.52 
0.57 
0.72 
0.01 
0.05 
0.41 
0.31 
0.31 
0.13 
0.12 
0.23 
0.44 
0.67 
0.27 
0.49 
0.52 
0.44 
0.38 
0.07 
0.08 
0.63 


lodin 
number 


90 

79 
188 
213 
273 
326 
258 
125 
309 

82 
187 
123 
122 

88 
139 

36 
101 

22 

69 
273 
224 


•  Figures  are  for  1000  c.c.  of  blood. 

examination  of  the  spleen  he  found  thickened  walls  in  the 
arterioles  and  intense  congestion  of  the  pulp.  He  assumes, 
therefore,  that  the  blood  seeks  the  path  of  less  resistance 
through  Weidenreich'sopen  capillaries  into  the  pulp,  where 
they  are  destroyeil,  presumably  by  contact  with  tlie  con- 
nective tissue.    From  this  rather  fantastic  point  of  view, 


268 


THE  SPLEEN  AND  AN^:MU 


splenectomy  therefore  becomes  equivalent  to  tying  off  a 
ruptured  blood-vessel. 

Summary. — The  several  diseases  described  in  this 
chajiter  not  only  have  sufficiently  characteristic  and  con- 
stant symptom-complexes  to  permit  a  differential  diagno- 
sis to  be  matle,  but  are  also,  in  all  probability,  due  to  dif- 
ferent causes,  or  possibly  to  a  common  factor  operating 
in  different  ways.  In  a  strict  sense,  none  of  them  should 
be  considered  as  primary  anaemias,  though  in  some  it  is 
difficult  or  impossible  to  find  the  "  causa  causorum."  From 
the  aspect  of  the  chief  lesion  found  (namely,  the  changes 
in  the  blood),  they  may  be  divided  into  two  groups,  in 
one  of  which  increased  blocxl  destruction  and  in  the  other 
impaired  blood  formation  is  characteristic.  As  will  be 
shown  in  a  later  chapter,  the  relative  importance  of  these 
features  has  an  important  bearing  on  the  results  produced 
by  transfusion  and  splenectomy.  From  this  point  of  view, 
the  anaMuia  of  Banti's  and  Gaucher's  diseases  is  chiefly  due 
to  impaired  blood  formation,  while  that  of  the  haMiiolytic 
jaundices  is  due  to  impaired  blood  destruction.  Finally, 
in  another  disease,  pernicious  anamia,  commonly  treated 
by  splenectomy,  increased  hamolysis  predominates,  but  is 
usually  acx'ompanied  by  seriously  impaired  powers  of  blood 
formation. 


CHAPTER  XII 


METHODS  OF  VALUE  IN  THE  DIAGNOSIS  AND  PROG- 
NOSIS OF  SPLENIC  DISEASE 

The  numerous  points  of  resemblance  or  of  slight  dis- 
similarity in  the  several  clinical  conditions  analyzed  in  the 
previous  chapter  demonstrate  that  in  a  given  case  careful 
study  must  usually  be  made  before  a  proper  diagnosis  can 
l)e  reached  and  such  studies  continued,  if  the  prognosis  and 
effect  of  treatment  are  to  be  properly  gauged.  An  impor- 
tant part  of  these  studies  is  not  only  the  performance  of 
certain  special  tests  to  be  described  in  this  chapter,  but  also 
the  proper  accomplishment  of  the  usual  hlstor>'  taking, 
physical  examination,  and  routine  blood  examinations. 

In  history  taking,  emijliasis  should  be  laid  on  a  most 
thorough  inquiiy  into  the  family  history-  for  evidence  of 
disease  of  a  similar  nature,  either  in  the  present  or  former 
generations.  Not  only  should  exhaustive  search  be  made 
into  the  patient's  or  parents'  past  histories  for  possible 
underlying  or  contributory  causes,  but  also  the  most  prob- 
able time  of  onset  of  the  disease  nmst  be  carefully  investi- 
gated. Experience  has  shown  that  it  is  in  connection  with 
these  three  points  that  most  defective  histories  are  at  fault. 
The  physical  examination  should  always  include  careful 
investigation  into  the  presence  or  absence  of  jaundice,  and 
the  size  of  the  liver,  spleen,  and  lymph-nodes.  Evidence 
of  jaundice  should  be  sought  not  only  in  the  skin  and 
mucous  membranes,  but  by  appropriate  tests  of  the  urine 

269 


270 


THE  SPLEEN  AND  AN.EMIA 


and  by  inspection  of  the  blood  se/um.*  Frequently  re- 
peated routine  blood  examinations  should  be  made.  The 
chief  fault  in  connection  with  such  examinations  is  that  they 
are  not  repeated  often  enough,  both  before  diagnosis  has 
been  readied  and  while  the  effect  of  treatment  is  being 
studied. 

The  special  laboratory  tests  to  be  described  in  this 
chapter  are  all  concerned  with  attempts  to  study  as  nearly 
quantitatively  as  may  be  both  the  nature  and  degree  of  the 
disease  process  (estimation  of  amount  of  blood  destruction, 
changes  in  the  blood-serum  and  in  the  resistance  of  erythro- 
cytes), and  the  ability  of  the  body  to  compensate  therefor 
(evidences  of  blood  regeneration).  It  must,  however, 
always  be  remembered  that  the  constantly  changing  factors 
of  blood  destruction  and  blood  regeneration  are  being  dealt 
with,  so  that  conditions  may  be  met  with  in  which:  (1) 
Blood  destruction  is  excessive,  but  powers  of  regeneration 
well  presen-ed  (as  in  hemolytic  jaundice) ;  (2)  blood  de- 
struction excessive  and  powers  of  regeneration  insufficient 
(as  in  pernicious  and  aplastic  ana?mia)  ;  (3)  blood  de- 
struction not  excessive,  but  powers  of  regeneration  insuf- 
ficient (as  in  Banti's  and  Gaueher's  disease),  with  an  in- 
finite number  of  intermediate  grades.  Such  considerations 
are  further  complicated  by  the  fact  that  the  bone-marrow 
response  may  be  considerable,  but  pathological  in  type,  as 
in  remission  stages  of  pernicious  anjemia.  It  must  also  be 
rememl)ered  that,  although  fairly  accurate  indirect  methods 
exist  for  estimation  of  the  amount  of  blood  destruction, 


*  Blood  should  be  withdrawn  from  c  i-  or  finger-stab  into  a  pointed 
glass  tube  of  small  calibre,  which  is  then  sealed  by  heat  and  allowed 
to  stand  for  several  hours. 


VALUE  IN  DIAGNOSIS  AND  PROGNOSIS 


471 


the  study  of  blood  regeneration  is  still  largely  qualitative. 
The  tests  referred  to  may  be  considered  under  the  fol- 
lowing heads: 

A.  Kesistance  of  erj'throcytes. 

B.  Evidences  of  bone-marrow  activity  (recticu- 

lated  cells;  nucleated  forms,  platelets). 

C.  Agglutinins   and   ha;niolysins   in   the   blood- 

serum. 

D.  Urobilin  excretion. 

E.  Protein,  iu*ic-acid  and  iron  metabolism. 

A.  Resistance  of  Erythrocytes  to  Hypotonic  Salt 

Solution 

The  resistance  (fragility)  of  er\'throcytes  to  various 
fluids  was  first  studied  by  Malassez -'^'  in  1873,  and  the 
mechanism  of  the  destruction  of  the  red  blood-cell  has  been 
more  or  less  imperfectly  understod  since  the  time  of  Ham- 
burger's **'  investigations  on  osmosis  of  body  fluids. 
Although  hypotonic  salt  solution  in  varying  strengths  has 
been  the  most  commonly  used  in  clinical  tests,  saponin, 
snake  venom,  bacterial  luemolysins,  and  specific  htemolytic 
inmiune  serums  have  also  been  employed  either  as  clinical 
tests  or  in  attempts  to  explain  the  mechanism  of  the  de- 
struction of  the  erythrocyte.  As  a  general  rule,  if  the  re- 
sistance of  erythrocytes  is  increased  or  decreased  to  one  of 
these  agents,  it  will  be  so  to  all,  but  occasional  exceptions 
have  been  noted.  Thus  in  obstructive  jaundice  and  in 
pernicious  antemia  it  has  been  clai'ned  that  the  resistance 
of  erythrocytes  to  saponin  is  diminished,  whereas  it  is  in- 
creased to  hypotonic  salt  solutions.  In  our  own  work,  on 
the  other  hand  (see  page  42),  we  have  foimd  that  in 
animals  under  various  experimental  conditions  the  changes 


272 


THE  SPLEEN  AND  ANAEMIA 


'"'if  ■■<: 


in  resistance  to  saponin  and  hypotonic  salt  solution  were 
always  parallel.  On  account  of  such  possible  divergences, 
however,  it  is  advisable,  for  the  present  at  least,  to  confine 
routine  tests  to  the  hypotonic  salt  solution  method. 

This  method  depends  on  the  simple  principle  that  ery- 
throcytes can  remain  for  some  hours  in  isotonic  salt  solu- 
tion without  damage,  whereas  when  placed  in  distilled 
water  they  are  verj^  quickly  ha?molyzed,  the  hemoglobin 
being  "  lakcd  out"  of  the  corpuscular  stroma.  If,  then, 
suitable  intem.ediate  strengths  of  solution  are  arranged, 
it  can  be  determined  in  just  what  strengths  of  salt  solution 
partial  ha'molysis  occurs,  and  at  which  point  complete 
haemolysis  first  occurs.  The  various  ways  of  applying  this 
test  have  been  considered  in  detail  by  Ribierre,^'*'  the 
method  finally  adopted  by  him  being  as  follows:  Glass- 
ware should  be  sterilized  and  the  chemically  pure  sodium 
chloride  should  be  desiccated  before  preparation  of  stock 
solutions,  to  get  rid  of  the  "  water  of  interposition."  In 
normal  cases  nine  small  tubes  are  arranged  in  strengths 
varying  as  follows:  0.50,  0.46,  0.44,  0.42,  0.40,  0.38,  0.34, 
0.32,  0.28  per  cent.  NaCl.  (If  it  is  found  that  haemolysis 
occurs  at  0.50  per  cent.,  a  second  test  is  made  with  solutions 
of  the  strengths  0.60,  0.56,  0.52. )  The  finger  of  the  patient 
is  carefully  cleansed,  pierced  in  the  usual  manner,  and  blood 
sucked  into  a  pipette  to  a  mark  denoting  one-fiftieth  of  the 
content  of  the  pipette  (about  2  c.c).  It  is  then  filled  with 
the  appropriate  strength  of  salt  solution,  mixed  and  emptied 
into  one  of  another  series  of  small  tubes,  avoiding  as  much  as 
possible  the  admixture  of  air,  and  the  operation  is  repeated 
through  the  series  of  tubes.  These  are  then  covered  with 
rubber  caps,  allowed  to  stand  five  minutes,  centrifuged  for 
one  and  one-half  minutes,  and  the  results  observed.  Ribierre 


VALUE  IN  DIAGNOSIS  AND  PROGNOSIS 


273 


has  found  that,  a.'though  after  twenty-four  hours  the 
amount  of  haemolysis  is  slightly  increased,  there  is  no  ap- 
preciable difference  between  a  five-minute  and  a  three- 
or  four-hour  period.  Many  observers  still  consider  it 
necessary  to  defibrinate  and  wash  the  erj'throcji;es ;  but  this 
not  only  requires  greater  quantities  of  blood  and  consid- 
erably increases  the  difficulty  of  the  examination,  but  also 
to  a  slight  extent  mechanically  injures  the  cells,  so  that 
a  slightly  lessened  resistance  is  found.  To  be  sure,  Widal, 
Abrami,  and  Brule  showed  that  in  some  cases  of  the  ac- 
(juired  form  of  hfwnoly tic  jaundice  with  apparently  normal 
resistance  fragility  would  be  demonstrated  if  the  cells  were 
washed  free  of  plasma.  Later  work,  however,  both  in  this 
laboratory  and  elsewhere,  has  tended  to  show  that  any 
change,  when  present,  is  in  the  cells  themselves. 

In  nur  work  in  this  laboratory',  both  on  patients  and 
animals,  the  use  of  a  mixing  pipette  has  been  found  un- 
necessary, the  measurement  of  many  drops  to  each  tube 
tedious,  and  sedimentation  for  one  hour  has  proved  prefer- 
able to  centrifugalization.  The  test  is  therefore  performed 
as  follows: 

Stock  solutions  of  sodium  chloride  are  prepared  as 
alK)ve  described  in  strengths  varying  by  0.02  per  cent, 
from  0.20  to  0.70  per  cent.  If  kept  tightly  stoppered  these 
may  be  used  for  several  months,  but  should  be  renewed 
earlier  if  control  tests  show  any  change  in  concentration 
of  solutions. 

A  series  of  twelve  or  more  tubes  containing  1  c.c.  of 

different  strengths  of  hypotonic  salt  solution  are  then 

arranged,  varying  by  0.C2  per  cent,  from  0.25  per  cent,  to 

0.60  per  cent,  (or  even  stronger,  if  diminished  resistance 

18 


174 


THE  SPLEEN  AND  ANEMIA 


K 


.fe  A 


.■uJ 

I  -  Ik   It* 


is  suspected) .  Into  each  one  drop  of  whole  blood  is  intro- 
duced and  the  tube  gently  shaken.  If  the  drops  have  been 
of  differenv  size,  slightly  more  blood  may  occasionally  have 
to  be  added  until  the  color  is  the  same  in  all.  After  stand- 
ing two  hours  at  room  temperature,  in  the  stronger  solu- 
tions in  which  no  hftmolysis  has  occurred,  the  unchanged 
corpuscles  at  the  bottom  of  the  tube  will  be  overlaid  with 
colorless  salt  solution.  In  the  weakest  solutions  all  cor- 
puscles will  have  been  hfemolyzed,  forming  a  transparent 
red  solution.  In  the  intermediate  tubes  can  be  noted 
the  point  at  which  haemolysis  begins  and  at  which  it  is 
complete. 

In  normal  cases  haemolysis  begins  at  al>out  0.45  and  is 
complete  at  0.35  per  cent.  In  a  case  of  the  familial  type 
recently  examined  haemolysis  began  Ps  high  as  0.7  per 
cent,  and  was  already  complete  at  0.475  per  cent.  In  most 
other  anaemias  the  resistance  is  nearly  always  more  or  less 
increased,  depending  on  the  severity  of  the  anaemia. 
Hjcmolysis  may  not  begin  until  solutions  as  low  as  0.36  are 
reached,  or  may  not  be  complete  before  0.24  or  0.26  per 
cent.  In  pernicious  ana?mia,  while  the  resistance  is  usually 
greatly  increased,  cases  have  been  reported  in  which  the 
resistance  is  normal  or  even  diminished,  so  that  there  is  a 
marked  resemblance  to  haemolytic  jaundice. 


B.  Evidences  of  Boxe-Maerow  Activity 

1 .  By  Vital  Staining.     Skeined  or  Reticulated  Cells. 

Amidst  the  confusion  that  surrounds  the  subject  of  stain- 
able  granules  in  the  erythrocytes,  a  few  facts  are  generallv 
accepted  by  lijcmatologists.  One  such  is  that  a  basophilic 
reticulation  is  demonstrable  by  the  methods  of  vital  stain- 


VALUE  IN  DIAGNOSIS  AND  PROGNOSIS 


«74 


ing  in  a  very  small  percentage  of  noraial  cells,  but  in 
greatly  increased  numbers  in  various  diseased  conditions 
of  tlie  blood.  This  special  method  of  examination  was 
first  described  by  Chaufiard  and  Fiessinger,'^  in  1907,  in 
connection  with  their  study  of  a  case  of  congenital  ha'mo- 
lytic  jaundice,  in  which  condition  the  reticulated  (granu- 
lous  or  skeined)  erythrocytes  are  verj'  nmch  increased. 
These  authors  used  Pajjpenheim's  pyronine  methyl  green 
stain  (equal  pj'rts  of  saturated  aqueous  solutions  of  pyro- 
nine and  methyl  green,  prepared  at  least  several  days 
before  use,  and  filtered  just  before  using),  but  also  sug- 
gest the  use  of  neutral  red  in  isotonic  solution,  while  W'idal 
recommends  polychrome  methylene  blue,  and  we  have 
found  the  best  results  with  brilliant  cresyl  blue. 

This  simple  test  is  performed  as  follows :  A  few  grains 
of  the  stain  are  dissolved  in  a  perfectly  clean,  small  test- 
tube  in  1  c.c.  of  noinial  salt  solution,  together  with  one  or 
two  small  cr}-stals  of  potassium  oxalate,  to  prevent  rou- 
leaux formation.*  As  the  exact  strength  of  the  solution 
is  inunaterial,  it  is  sufficient  to  prepare  the  stain  in  this  way, 
aiming  to  get  a  strength  of  solution  that  is  just  trnnslucent 
in  a  test-tube  of  1  cm.  diameter.  A  few  drops  of  ./lood  are 
allowed  to  flow  into  this  tube,  the  mixture  gently  shaken 
and  allowed  to  stand  ten  or  fifteen  minutes.  A  drop  of 
the  sediment  is  then  pipetted  off,  a  fresh  cover-slip  prepa- 
ration made  and  examined  under  an  oil  immersion  lens. 
The  blue-staining  reticulum  is  easily  visible  under  such 
conditions,  and  the  percentage  of  reticulated  to  non-reticu- 
lated erythrocytes  estimated.  The  protoplasm  of  the  ery- 
throcytes  is  not  affected  by  the  stain,  whereas  the  various 

*  The  solution  of  sodium  oxalate  in  salt  solution  may  be  prepared 
beforehand  and  kept  on  hand,  if  the  test  is  made  frequently. 


876 


THE  SPLEEN  AND  ANEMIA 


■IX- 


t 

'     1 


Ik 


i  "  '' 

■'.■> 


forms  of  leucocytes,  the  platelets,  and  ha'mokoiiiuin  are 
readily  stained  and  identified.  The  avera<^e  diameter  of 
the  reticulated  cell,  accordinff  to  Chauff  ard  and  Fiessinger, 
is  8.1 /*,  as  compared  with  an  average  diameter  of  (J.3^  for 
the  non-reticulated  cell. 

The  reticulum  p  -rsists  longer  than  the  protoplasm  of 
the  erythrocyte  ur  or  the  conditions  of  this  test,  but  the 
majority  of  both  will  disappear  in  the  course  of  a  few 
hours.  If  an  accurate  comparative  count  is  to  be  made,  the 
cover-slip  should  be  prepared  and  examined  between  fif*^een 
and  thirty  minutes  of  the  time  of  obtaining  the  blood. 

In  the  blood  of  normal  human  subjects,  reticulated 
erythroc}'tes  are  either  entirely  absent  or  constitute  but 
a  very  small  fraction  of  one  per  cent.  They  tend  to  be 
slightly  increased  in  any  considerable  anaemia,  but  rarely 
exceed  1  to  4  per  cent.  Thus  Chauff  ard  and  Fiessinger 
found  an  average  of  one  cell  in  .500  and  one  in  400  in  eases 
of  tuberculosis,  one  in  400  and  one  in  600  in  mitral  disease, 
one  in  GOO  in  malaria,  one  in  500  in  plumbism,  one  in  200 
in  chronic  nephritis,  and  one  in  100  and  one  in  50  in  plumb- 
ism with  nephritis.  In  a  case  of  tuberculous  nephritis  with 
profound  amemia,  subicterus,  and  diminished  resistance 
of  erythrocytes,  the  reticulated  forms  were  considerably 
increased  (2  per  cent.).  In  cases  of  hJEmolytic  jaiindice, 
on  the  other  hand,  the  percentages  of  reticulated  forms 
reach  as  high  as  15  to  20  per  cent.,  and  in  the  case  reported 
in  the  previous  section  of  this  book  (page  202)  the  counts 
were  frequently  above  5  per  cent.  The  proportion  of 
reticulated  cells  varies  considerably  in  different  species, 
these  cells  in  the  normal  dog  being  even  rarer  than  in  man, 
whereas  in  the  rabbit  they  constitute  about  2  per  cent,  of 
the  total  number. 


|,-U  .i 


VALUE  IN  DIAGNOSIS  AND  PROGNOSIS 


277 


The  nature  of  the  reticulated  erythrocytes  has  not  yet 
been  demonstrated,  but  whether  the  reticula  are  nuclear 
fragments  of  immature  er>'throcytes,  indicating  a  bone- 
marrow  reaction  '(as  has  been  generally  considered),  or 
are  the  results  of  a  disease  process,  their  identification  is 
of  great  diagnostic  value,  and  their  diminution  or  disap- 
pearance as  the  result  of  treatment  may  be  taken  as  a  s'gn 
of  good  prognostic  significance. 

2.  Bji  Fired  Smears  (Nucleated  forms,  Howe  -Jolly 
bodies,  etc.). — Although  no  direct  method  exists  of  deter- 
mining the  rate  of  blood  formation,  it  may  be  considered 
as  equal  to  blood  destruction  (as  estimated  from  urobilin 
excretion,  etc.)  so  long  as  the  blood  counts  remain  con- 
stant. Although  even  this  method  fails  if  the  count  is  rising 
or  falling,  nevertheless  under  all  conditions  some  criteria 
exist  for  estimating  the  effort  required  of  the  !)lood-form- 
ing  organs  (mainly  bone-marrow)  to  maintain  the  cellular 
elements  of  the  blood  at  the  level  they  happen  to  be.  Thus 
in  the  stained  dried  smear  of  the  peripheral  blood,  stained 
with  any  of  the  Romanousky  group  of  stains,  the  presence 
of  nucleated  forms  may  l>e  taken  as  evidence  that  the  bone- 
marrow  is  so  hard  pushed  that  it  must  allow  immature 
forms  to  appear  in  the  peripheral  blood.  If  tlie  nucleated 
erythrocytes  are  megaloblasts.  the  diagnosis  of  pernicious 
aniemia  is  strongly  suggested,  but  it  must  not  be  forgotten 
that  other  chronic  anaemias,  particularly  tliose  in  which 
small  hemorrhages  occur  over  long  periods  of  time,  can 
iilso  produce  megaloblasts  in  the  peripheral  drculation.  It 
must  also  be  remembered  that  in  certain  rare  condi';ions, 
such  as  tumors  of  the  bone-marrow,  ervthroblasts  mav 
appear  in  the  peripheral  circulation  without  indicating 
excessive  blood  regeneration. 


278 


THE  SPLEEN  AND  ANEMIA 


•      ■!•    .1. 


HoweU-Jolly  bodies  and  the  Cabot  ring  forms  should, 
like  tlie  reticulated  forms,  be  taken  as  evidence  of  the  de- 
mand on  the  bone-i.arrow  for  increased  blood  formation 
and  of  Its  ability  to  respond  to  the  same.    The  increased 
number  of  these  and  of  nucleated  forms  after  blood  trans- 
fusion or  splenectomy  (so-called  "  blood  crisis  ")  are  simi- 
larly taken  as  the  response  to  the  bone-marrow  stimulation 
that   these   operations   cause.      These   so-called    "blood 
crises"  will  be  considered  again  in  the  chapter  on  the  results 
of  splenectomy  mider  the  heading  of  "  Pernicious  Ans- 
nua,     in  which  condition  they  have  been  most  carefdly 
studied;  but  it  should  be  noted  that  thev  have  also  been 
observed  rfter  splenectomy  in  Banti's  disease,  h^emo'-  tic 
jaui.dice,  and  other  conditions.    If  absent  after  splenec- 
tomy when  the  blood  comit  is  rising  (as  in  Goldschmidt, 
1  epper,  and  Pearce's  case),  it  would  indicate  that,  with 
the  cessation  of  increased  h.-emolysis,  the  bone-marrow  is 
no  longer  forced  to  put  forth  immature  forms.    If  on  the 
other  hand,  both  blood  crisis  and  improvement  in  blood 
count  are  wanting,  it  would  indicate  that  an  exhausted 
bone-marrow  is  no  longer  capable  of  responding  to  stimu- 
lation with  the  production  of  even  these  immature  forms 
The  blood  crisis,  which  so  frequently  follows  splenec- 
tomy for  splenic  disease,  has  been  shown  in  Chapter  II  to 
be  practically  absent  after  removal  of  the  normal  spleen. 
This  apparent  discrepancy  is  similar  to  the  fluctuations 
in  the  red  blood-cell  count  after  splenectomy,  which  falls 
after  removal  of  the  normal  spleen,  but  rises  after  splenec- 
tomy m  splenic  disoase.     The  most  probable  explanation 
of  both  paradoxes  seems  to  be  that  in  disease  the  improve- 
ment IS  due  to  the  removal  of  an  agent  which  both  causes 
excessive  haemolysis  and  depresses  Ixine-marrow  function. 


VALUE  IN  DIAGNOSIS  AND  PROGNOSIS  «70 

whereas  the  anamia  following  nonnal  splenectomy  is  due 
to  loss  of  nonnal  stimulus  to  blood  formation,  and,  for  the 
same  reason,  unusual  signs  of  bone  activity  are  lacking. 

Polvchromatophilia,  like  the  presence  of  microcytes 
and  poikilocytes  in  the  blood  stream  ^Rous)^*'"  probably 
indicates  degeneration  of  the  erythrocyte  rather  than  the 
appearance  of  immature  forms.    Macrocytes,  like  megalo- 
blasts,  are  probably  signs  of  perverted  bone-marrow  activ- 
ity.    The  diminution  or  increase  of  the  number  of  such 
forms,  mav,  however,  safely  be  taken  as  indicative  respect- 
ively of  amelioration  or  aggravation  of  the  disease  process. 
3.  Blood    Platelets    and    LeiLConjtes.—lf    Wright's 
theorj'  l>e  accepted,  that  the  blo^jd-platelets  are  independent 
elements  of  the  blood  formed  from  the  megakaryocytes  of 
the  bone-marrow,  both  leucocytes  and  platelets*^"  enter 
inu>  the  problem  of  blood  regeneration.     The  leukopenia 
and  the  diminished  platelet  counts  found  in  many  of  the 
diseases  here  under  consideration  should  therefore  be  taken 
as  further  evidence  of  deficient  biuod  formation.     The 
increase  in  bloo<l-platelets  observed  by  Lee,  Vincent,  and 
Robertson-^'   after  splenectomy,  may  therefore  be  con- 
sidered another  factor  in  the  "  blood  crises  "  previously 
described.    In  disease  conditions  a  gradual  change  in  these 
elements  of  the  blood  in  the  direction  of  normal  figures 
should  also  be  taken  as  a  sign  of  improvement,  though  not 
necessarily  of  permanent  improvement. 

C.  Agglutinins  and  H^^MOLVsiNb  in  the  Blood-seeum 
1.  Auto-agglutinins.—A  simple  test  that  Widal, 
Abrumi,  and  Brule  ^''  have  found  of  value  in  differentiat- 
ing the  congenital  and  acquired  types  of  htemolytic  jaun- 
dice is  that  suggested  by  Brule  after  the  method  of  Pagniez 


tl 


•f    tl 


E  il 


i . 


■iff 

rt; 


280 


THE  SPLEEN  AND  /VN^MIA 


for  the  pi-esence  of  auto-agglutiriins  in  the  seruni.     This 
tejt  consists  merely  of  mixing  one  drop  of  the  patient's 
washed  red  blood-cells  with  ten  drops  of  the  patient's  own 
serum  in  a  watch-glass.    If  positive,  after  some  seconds, 
the  mixture  loses  its  Homogeneous  aspect,  visible  granules 
of  agglomerated  corpuscles  are  evident  on  agitating,  and 
finally,  after  several  minutes,  a  distinct  pellicle  forms  that 
sinks  to  the  bottom  and  does  not  mix  with  the  clear  serum 
on  shaking.    In  doubtful  cases  the  result  can  be  confirmed 
by  microscopic  examination.    Widal,  Abrami,  and  Brule 
found  this  test  intensely  positive  in  three  cases  of  acquired 
hjcmolytic  and  negative  in  two  cases  of  tiie  congenital  type, 
and  also  negative  in  cases  of  alcoholic  cirrhosis,  siinple 
catarrhal  jaundice,  and  other  conditions.    They  state  that, 
while  "  iso-agglutination  "  ( agglutina,        -f  corpuscles  by 
serum  of  subjects  of  the  same  specie       ..   frequently  ob- 
served  (00.9  per  cent,  of  cases,  according  to  Pagniez). 
auto-agglutlnation  is,  so  far  as  they  know,  never  positive 
except  in  this  condition. 

2.  AutoJysim,  Isnh/dm,  and  Heteroli/ mm. —The  he- 
molytic power  of  the  patient's  semm  may  be  tested  on 
his  own  blood-corpuscles  (autolysis),  on  the  corpuscles  of 
other  human  blood  (isolysis),  or  on  the  corpuscles  of  an- 
other   species    (heterolysis)     (see   Widal    and    Wiessen- 
bach*'  =  ).     To  twenty  drops  of  the  patient's  fresh  serum 
is  added  one  drop  of  washed  red  blood-corpuscles  from 
the  appropriate  source.    The  mixture  is  incubated  at  37° 
for  thirty  minutes  and  the  existence  and  degree  of  ha?mo- 
l3'sis  noted  in  the  color  of  the  supernatant  fluid.     Tests 
for  heterolysins  are  of  little  valr-,  a«  they  are  frequently 
present  in  normal  sera.    Comparative  tests  may  l>e  mad'e 
with  tul)es  containing  different  amounts  of  the  patient's 


VALUE  IN  DL\GNOSIS  AND  PROGNOSIS 


281 


senun  and  the  results  compared  with  those  in  similar  tests 
of  known  normal  blood.  Wliile  positive  tests  for  auto- 
lysis have,  so  far  as  I  know,  never  been  reported,  Chauf- 
fard,  Widal,  and  Weissenbach  and  others  have  reported 
cases  that  at  times  of  exacerbation  of  the  disease  ^ive  a 
positive  "  isolysin "  test,  indicating  the  presence  in  the 
serum  at  these  times  of  a  free  hemolysin.  During  periods 
of  remission  these  isolysins  were  not  found.  It  must,  of 
course,  be  rememl)ered  that  Moss^"'"'  and  others  have 
found  that  the  blood  of  a  certain  percentage  of  individuals 
is  normally  isolytic  and  isoagglutinative  to  the  blood  of 
other  individuals  of  the  same  species. 

D.  Urobimx  Excretion 

It  is  now  generally  recognized  that  in  the  estimation 
of  the  amount  of  urobilinogen  and  urobilin  excreted  in 
the  urine  and  stools  there  exists  a  fairly  accurate  index 
of  the  amount  of  blood  being  destroyed  in  the  body. 
Emphasis  has  been  laid  throughout  tliis  book  on  the  impor- 
tance of  the  study  of  blood  destruction  in  its  relation  to 
the  spleen,  and  it  is  Eppinger's'"*  great  serv^ice  to  have 
l)rought  us  to  recognize  the  importance  of  urobilinogen 
and  urobilin  excretion  in  the  stool  as  the  best  index  of 
such  destruction.  Instead  of  such  indefinite  criteria  as  an 
enlarged  spleen,  tendency  to  acholuric  jaundice,  or  the 
existence  of  anaemia  coincident  with  active  blood  formation, 
Eppinger  was  led  to  search  for  a  more  definite  index,  and 
found  it  in  Charnas's  spectroscopic  method  f.^r  the  quanti- 
tative estimation  of  the  amount  of  urobilinogen  and  uro- 
bilin in  the  stool.  Although  this  has  been  generally  re- 
placed bv  the  Wilbur  and  Addis  *''^  method,  it  still  remains 
jnly  roughly  quantitative  and  a  rather  disagreeable  and 


I 


«t 


THE  SPLEEN  AND  ANJiMIA 


I 


time-consuming  test,  so  that  improved  methods  are  still 
to  be  hoped  for.  Emphasis  must  be  laid,  however,  on  the 
fact  that  examination  of  the  stool  as  well  as  the  urine 
is  essential:  for.  while  urobilin  is  more  apt  to  be  present 
in  the  urine  when  there  is  an  increased  amount  of  blood 
destruction  than  in  normal  conditions,  this  is  in  the  nature 
of  an  overflow  through  the  liver,  and  may  he  absent  when 
there  are  still  greatly  increased  amounts  in  the  stool ;  and, 
furthermore,  the  amount  of  urobilinuria  may  be  influenced 
by  a  poorly  functioning  liver. 

Method.— The  method  for  estimating  the  amount  of 
urobilinogen  and  urobilin  in  the  stools  is  described  by 
Wilbur  and  Addis  as  follows: 

URINE 

"  The  method  of  collection  of  the  twenty-four-hour 
urine  has  a  considerable  effect  on  the  total  spectroscopic 
reading.  The  vessel  in  which  the  urine  is  collected  should 
be  of  dark-brown  glas.f,  and  should  he  kept  in  darkness. 
Thymol  crystals  should  be  added,  for,  even  in  cases  in 
which  no  obvious  fermentation  had  occurred,  we  sometimes 
found  a  diminution  in  the  total  amount  if  no  pres"rvative 
was  present.  After  measuring  the  amount  of  the  twenty- 
four-hour  ui-ine,  10  c.c.  are  mixed  with  10  c.c.  of  a  saturated 
alcoholic  solution  of  zinc  acetate  and,  after  a  few  minutes, 
filtered.  If  a  number  of  urines  are  being  examined  at  the 
same  time,  it  is  convenient  to  have  test-tubes  graduated  to 
10  and  20  c.c.  Ten  cubic  centimetres  of  the  filtrate  are 
taken  and  1  c.c,  of  Ehrlich's  solution*  is  added.  It  was 
found  that  this  amount  prnduc^d  a  sufficient  concentration 

*    Paradimethylaminolx-nzaldehyde,    20    jftn. ;   concentrated   hydro- 
chloric acid,  150  c.c;  water,  150  c.c. 


VALUE  IN  DIAGNOSIS  AND  PROGNOSIS 


28S 


of  acid  in  the  mixture  to  give  the  maximum  intensity  of 
the  urobilin  band  and  contained  enough  of  the  paradi- 
incthylamidobenzaldehyde  for  the  reaction  with  urobilino- 
gen. The  development  of  the  urobilinogen  band  is  not 
instantaneous.  We  found  that,  as  a  rule,  it  had  attained 
its  full  intensity  in  a  quarter  of  an  hour.  The  action  can 
he  greatly  accelerated  by  heating,  but  this  is  to  be  avoided. 
It  is  better  to  wai*-  for  an  hour  before  making  the  reading, 
and  during  this  time  the  solution  should  be  kept  in  the 
dark.  After  three  or  four  hours  there  is  a  diminution  of 
the  urobilin  and  urobilinogen  in  filtrates  from  urines,  so 
the  estimation  should  be  made  not  later  than  three  hours 
after  adding  the  Ehrlich  solution.  We  found  that  Citron's 
hand  spectroscope  *  was  the  most  convenient  instrument 
to  use.  The  filtrate  was  washed  into  a  graduate  and  diluted 
with  tap-water  until  first  one  and  then  the  other  band  of 
light  absorption  had  disappeared  when  the  full  amount  of 
light  entered  the  spectroscope,  but  were  still  visible  when 
the  light  was  partly  shut  off.  This  gives  a  fairly  definite 
end-point,  and  we  did  not  find  any  great  variation  in  the 
readings  made  by  different  persons,  it  is  important,  of 
course,  that  the  light  shall  be  always  of  approximately 
equal  intensity.  We  made  the  readings  in  a  dark  room 
with  a  tungsten  electric  bulb,  holding  the  spectroscope 
close  to  the  source  of  light.  In  highly-colored  urines  one 
may  be  in  doubt  as  to  whether  or  not  a  trace  of  urobilin  is 
present,  for  there  may  be  so  much  general  absorption  of 
hght  as  to  obscure  the  urobilin  band  in  the  undiluted  fil- 
trate. There  is  no  such  difficulty  with  the  urobilinogen 
band,  which  lies  between  the  red  and  yellow  where  there 

*  This  can  he  obtained  from  Paul  Altmann,  Luisenstrasse,  Berlin, 
Grrmany. 


il     i 


It     1 


i 


M 


1*1 

I  i 


884 


THE  SPLEEN  AND  AN/EML\ 


*:••> 


K 


I      ,k  Hi 

■•''■At  S 


IS  no  marked  Lght  absorption.  With  urines  containing  bile 
•f  he  amount  of  urobilin  is  not  very  large,  it  is  neeessty  t^ 
add  some  fuller  s  earth  and  to  leave  the  mixture  s'..-ding 
Or  some  t.n.e  before  filtration,    if  this  is  done  the  urobilin 
band  can  usually  be  read  even  in  the  undiluted  filtrate. 
I  he  dilution  required  gives  the  value  for  5  e.c.  of  urine 
I    this  figure  ,s  multiplied  by  the  number  of  5  c.c.  quan- 
tities m  the  twenty-four-hour  urine,  the  number  of  dilu- 
tions which  would  have  been  necessary  if  all  the  urobilino- 
gen and  urob-lm  in  the  twenty-four-hour  amount  had  been 
concentrates!  in  a  volume  of  .5  c.c.  is  obtained.     For  in- 
stance ,f  in  a  twenty-four-hour  urine  measuring  lOOO  cc 
a    reading    of    ten    dilutions    for    urobilinogen    and    of 
twenty  for  urobilin  were  mode,  the  total  un^bilin  would 

'/^^  ^,  f ';'  7=  ^'«^^-  ^^'^  t'-i"!  to  determine  the  <lilution 
value  of  definite  weights  of  urobilin  prepared  from  biliru- 
bin, but  d,fFe-ent  preparations  varied  so  much  in  their 
dilution  value  that  it  was  obvious  that  we  were  not  dealing 
with  pure  urobilin,  and  we  abandoned  any  attempt  to  ex- 
press our  results  in  milligrammes  of  urobilin. 

STOOLS 

"All  the  faeces  passed  in  the  twenty-four  hours  were 
collec  ed  m  the  same  receiver,  the  stools  being  protected 
froni  l.,.ht.    Thev  were  then  washed  into  a  large  gradut 
and  thoroughly  ground  up  with  water  into  a  homogc     oul 
paste,  and  water  added  to  0.5,  1,  or,  if  necessan-,  2  litres 
depending  on  the  quantity  of  stool.    After  thorough  mix- 
ing 2.5  c.c  were  taken  and  7.5  c.c.  of  acid  alcohol  (9.5  per 
cent,  alcohol,   ifiOO  c.c;  concentrated  hydrochloric  acid 
25  c.c.  and  water,  800  cc)  were  added.    The  mixture  was 
then  put  into  a  shaker  for  about  hnlf  an  hour.     A  consid- 


VALUE  IN  DIAGNOSIS  AND  PROGNOSIS 


28A 


erable  number  of  extractives  were  tried  for  removing  the 
urobilin  from  the  stools,  but  none  were  found  so  efficient 
us  alcohol  with  hydrochloric  acid.  After  thorough  mixing 
in  the  shaker,  an  equal  quantity  of  a  saturated  solution  of 
zinc  acetate  in  alcohol  was  added  and  the  mixture  was 
tiltcre<l.  After  adding  2  c.c.  of  Ehrlich's  reagent  to  20  c.c. 
of  the  filtrate,  the  solution  was  put  aside  in  a  dark  place 
until  next  day.  The  addition  of  zinc  acetate  is  not  abso- 
lutely essential,  but  in  some  cases  we  obsen-ed  an  intensi- 
fication of  the  urobilin  b-nd  following  its  use,  and  it  is 
perhaps  an  advantage  to  make  the  urine  and  stool  readings 
so  far  as  possible  under  the  same  conditions.  The  de- 
velopment of  the  urobilinogen  band  was  not  always  com- 
plete until  six  hours  had  elapsed,  but  thereafter  there  was 
no  loss  of  urobilinogen  or  urobilin  for  a  long  time,  although 
this  was  not  the  case  with  the  zinc  acetate  filtrates  before 
the  addition  of  Ehrlich's  solution.  The  reading  was  made 
in  the  same  way  as  with  the  urine  and  the  total  amount 
calculated  for  the  volume  of  stool  after  gi-inding  up  with 
water,  the  dilution  of  the  25  c.c.  by  acid  alcohol  and  zinc 
acetate  being  taken  into  account.  Instead  of  using  tap- 
water  for  dilution  of  the  final  extract,  60  per  cent,  alcohol 
was  required  to  avoid  the  development  of  a  precipitate." 

Wilbur  and  Addis  found  that,  wliile  urobilin  is  a  nor- 
mal constituent  of  the  urine,  the  amount  is  so  small  that 
ordinarily  it  can  be  demonstrated  only  by  extracting  large 
(juantities  of  urine.  A  p  Jsitive  result,  therefore,  in  twenty- 
four-hour  specimeir  indicates  an  abnormal  increase  over 
the  amounts  usually  present.  In  the  stools  of  ten  adults 
with  supposedly  normal  haemoglobin  metabolism  they  found 
that  the  average  daily  excretion  of  urobilin  varied  between 


t'f.! 


m  II 

m  I 


fl88 


TIIE  SPLEEN  AND  AN.EMIA 


j,  ,11  # 


3307  and  8737  dilution  values,  with  a  general  average  of 
6475.  It  is  important,  however,  to  note  that,  on  account 
of  the  wide  daily  fluctuations,  examinations  of  single 
twenty-four-hour  specimens  are  of  little  value.  So  long 
as  stools  were  kept  from  exposure  to  light  there  did  not 
seem  to  be  a  very  rapid  loss  of  urobilin,  and.  as  the  desired 
figures  represent  the  combined  value  of  urobilinogen  and 
urobilin,  the  amount  of  the  former  that  changes  to  the  latter 
while  standing  is  immaterial.  In  making  comparative 
studies,  however,  as  for  example  before  and  after  splenec- 
tomy, it  is  advisable  to  make  examinations  as  nearly  as 
possible  after  equal  amounts  of  time  have  elapsed  since  the 
collection  of  the  material.  While  Wilbur  and  Addis  were 
not  able  to  demonstrate  urobilin  in  the  blood-serum  with 
certainty,  they  found  their  method  was  applicable  to  the 
study  of  the  bile,  but  that  widely-varv'ing  figures  were 
obtained.  Thus  in  sixteen  diverse  cases,  unconnected  with 
excessive  blood  destruction,  10  c.c.  of  bile,  obtained  post- 
mortem, jnelded  dilution  values  varj'ing  between  0  and 
4.500.  As  will  be  shown  later,  this  finding  constitutes  a 
strong  objection  to  the  duodenal  tube  method  of  Schneider. 
In  applying  their  method  to  various  clinical  conditions, 
Wilbur  and  Addis  found  veiy  high  average  figures  in 
the  stools  of  cases  associated  with  increased  blood  destruc- 
tion. That  this  finding  may  be  useful  in  diagnosis  is  shovm 
by  the  fact  that,  whereas  two  cases  of  pernicious  ansemia 
had  average  figures  of  22,014  and  2J  Q77  respectively,  a 
case  of  secondary  ana?mia  showed  an  a^  .-age  of  only  2400. 
The  value  of  this  method  in  prognosis  and  in  studying 
the  results  of  treatment  is  shown  in  the  following 
paragraphs. 


VALUE  IN  DIAGNOSIS  AND  PROGNOSIS 


287 


By  Charnas's  method,  Eppinger  fi)und  that  the  normal 
adult  excretes  from  0.12  to  0.15  gm.  of  urobilin  per  day, 
and  that  these  figures  were  not  materially  increasetl,  or 
were  even  diminished  in  such  secondary'  anjrmias  as  those 
of  carcinoma,  Addison's  disease,  post-abortive  ana-niia,  and 
chlorosis.  In  cases  where  there  was  excessive  blood  de- 
struction, on  the  other  hind,  these  figures  were  greatly 
increased.  In  pernicious  antEmia,  for  instance,  he  found 
such  figures  as  0.24  gm.,  0.58  gnj.,  and  1.14  gins,  per  day, 
and  in  three  cases  of  haMnolytic  jaundice  the  enormous 
increase  of  1.75  gms.,  2.50  gms.,  and  3.05  gnis.  per  day. 
McKelvy  and  Rosenbloom  -'-  also  found  increased  urobilin 
excretion  in  a  case  of  ha^niolytic  jaundice.  In  a  case  of 
pernicious  anaemia  submitted  to  splenectomy,  Eppinger 
found  that  the  increased  urobilin  excretion  was  diminished 
to  mere  traces  after  operation,  and  one  of  the  cases  of 
ha?molj^ic  jaundice,  which  excreted  before  operation  2.96 
gms.  to  3.95  gms.  daily,  after  splenectomy  excreted  only 
0.062  and  0.70  gm.  daily. 

These  findings  have  been  confirmed  by  Robertson,'''* 
and  also  by  work  from  this  department  (see  page  202). 
Robertson  emphasizes  the  fact  that  cases  which  had  shown 
a  high  urobilin  excretion  before  splenectomy,  and  in  which 
after  splenectomy  the  urobilin  output  exhibited  only  a 
transient  reduction,  or  none  at  all,  did  not  show  as  much 
improvement  in  other  respects  following  the  operation  as 
did  those  cases  in  which  the  urobilin  output  was  perma- 
nently reduced  after  splenectomy.  The  cases  of  pernicious 
anemia  and  of  congenital  hsmolj-tic  jaimdice  studied  in 
this  department  before  and  after  splenectomy  have  been 
treated  in  detail  in  a  previous  chapter.    In  this  connection, 


« 


if.*  I 


iV 


mi 

W 
H 

BE  i 

H 


288 


THE  SPLEEN  AND  ANEMIA 


•:9* 


oHcver.  .t  should  be  noted  that  splenectomy  produced  a 
defarute  improvement  ,n  the  combined  urobihnogen  and 
urobdm  excretion  in  both  of  these  eases.     In  thj\.ase  o 
pernicious  ana-mia  before  splenectomy  the  urobilin  fi^nu-e 
(by  the  Udbui- and  Addis  inethod)  averaged  18,300  pe 
16, UO.        7  f'"  ^PJ-ectoniy  this  %ure  avera^xl 

10  000  per  day,  a  d.nnnution  too  slight  to  permit  of  si.- 
niheance  be.ng  attached  to  it.    Two  Uionths  after  splen  t 
ton.y,  however,  at  a  tin.e  when  the  blocxl  count  showed  a 
pronoiuiced  and  most  satisfactory  iiiiproven.ent    the  Jrc! 
bilin  output  had  fallen  to  one-sev^.th' f  its  foL  "^^ 
and  had  reached  a  low  normal  elin.ination.    In  the  ea^  «? 
congemtal  ha-molytic  jaundice,  urobilin  was  never  fo'nd 
mtheunne.    In  the  stools,  however,  tl       -lution  rec  :>  d 
[      r   ;\\   u"  "^  ^"'"'-""^-en  and  uruoilin   absorption 
hands    (Wdbur  and  Addis  n.eth.l),   over  two  per^X 
Ota  hng  ten  days  before  splenectomy  was  71,250;  wheret 
for  two  per,o,ls  totalling  eight  days  after  splenectomy  th^ 
figures  were  only  7954.  ^ 

Schneider  ••'-■has  recently  shown,  by  a  method  of  his 
OH^  devising,  that  r  ,.  .  titativc-  e.tinxate  nuy  be  ma.e 
of  the  urobilin,  urobilinogen,  and  bilirubin  in  the  duodenal 
contents,  obtained  through  a  duodenal  tube.  He  eonfi^n^ 
previous  work  in  finding  all  the  above  elements  increase 
in  permcious  ana-mia  and  diminished  or  absent  in  other 
conditions  simulating  pernicious  anemia.  He  considers 
the  pleochromia  found  to  be  an  expression  of  the  immediate 
ha.molysis,  ui-obilinocholia  an  expression  of  the  heaped 

7fv.'^Ti'"V"  *^^  P^'*^^  'y'''"^'  ^"^  *h^  ^'^Sh  color-index 
ot  the  blood  .n  pernicious  anemia  an  expression  of  the 
ovei^plus  of  haemoglobin-building  material  heaped  up  in 
the  liver.    Examination  of  a  single  specimen,  as  practised 


VALUE  L\  DIAGNOSIS  AND  PROGNOSIS 


288 


in  this  nit'thod,  iiowever,  even  though  the  sul)stance  sought 
for  mv-  he  in  greater  eoncentration,  is  so  much  less  de- 
sirahle  than  examination  of  the  total  collection  of  several 
(lays,  as  in  the  stool  method,  that  it  is  doubtful  whether 
tiiis  procedure  will  prove  as  useful  as  the  Wilbur  and 
Addis  test,  cumbersome  and  disagreeable  as  the  latter 
may  be.  It  has  already  been  pointed  out,  also,  that  Wilbur 
and  Addis  found  extremely  wide  variations  in  the  urobilin 
content  of  bile,  and  that  there  is  evidence  to  show  that  tiie 
tlaily  output  of  urobilin  varies  greatly  in  a  given  indi- 
vidual. Although  the  stool  method  fails  to  take  acco -nt 
of  the  urobilin  reabsorbed  by  the  intestine,  this  disad- 
vantage is  probably  more  than  counterbalanced  by  weak- 
nesses in  the  duodenal  method,  which  ignores  variations  in 
the  composition  of  the  bile  and  estimation  of  the  total 
(juantity  of  bile  secreted,  and  also  is  more  liable  to  errors 
in  the  collection  of  material. 


M  1 

I 


E.  Pkoteix,  Ukic-acid,  axd  Ikon  Metabolism 

Expression  of  the  need  for  proper  metabolic  studies  in 
the  diseases  considered  in  this  book,  the  best  methods  for 
studying  the  same,  and  the  lesults  hitherto  obtained,  both 
experimentally  and  clinically,  will  be  found  in  detail  in 
Chapters  VIII  and  X.  In  spite  of  the  fact  that  discor- 
cordant  results  are  there  recorded,  both  in  clinical  and  ex- 
perimental work,  a  few  facts  of  value  to  the  clinician  may 
safely  be  deduced.  In  severe  anaemias  an  increased  elimi- 
nation of  uric  acid  and  iron  is  found,  and  Umber's  work 
demonstrates  a  pathologically  excessive  destruction  of  pro- 
tein in  some  cases  of  Banti's  disease.  As  all  these  con- 
ditions of  metabolism  improve  after  splenectomy,  cases 

19 


il 


too 


THE  SPLEEN  AND  AN.EMIA 


showing  such  tlistui-bance  of  metabolism  should  probably 
be  considered  especially  suitable  for  splenectomy.  A  final 
decision  on  this  point,  however,  cannot  be  reached  until  a 
larger  number  of  metabolic  studies  are  at  hand,  and  for 
this  reason  it  is  desirable  that  complete  studies  of  this  kind 
should  be  made  whenever  conditions  are  favorable. 


CIIAPTEIl  XIII 

TREATMENT  OF  SPLENIC  DISEASES  BY  METHODS 
OTHER  THAN  SPLENECTOMY 

(1)  BLOOD  TRANSFUSION.  (2)  MEDICINAL  AND  HY- 
GIENIC  MEASURES.  (3)  SURGERY  OTHER  THAN 
SPLENECTOMY. 

Ix  tlie  treatment  of  certain  phases  or  of  individual  eases 
of  splenic  disease,  splenectomy  must  either  be  postponed 
or  be  considered  as  definitely  contra-indicated.  For  in- 
stance, in  very  late  stages  of  Banti's  disease  or  in  pernicious 
anifmia,  in  periods  of  exacerbation  with  extreme  ana-mia, 
or  in  the  crises  of  deglobulization  of  the  hiemolytic  jaun- 
dices recourse  to  splenectomy  may  be  impossible.  At  the 
other  extreme  of  the  scale,  some  cases  of  familial  jaundice, 
"  more  icteric  than  sick,"  are  so  little  incommoded  by  the 
disease  that  splenectomy  may  be  considered  unnecessary. 
In  these,  as  in  other  cases  where  the  operation  must  be 
postponed,  or  even  in  relapses  after  splenectomy  has  been 
performed,  certain  other  procedures  have  considerable 
value. 

1.  Blood  Transfusion. — The  most  important  of  these 
is  the  method  of  multiple  blood  transfusions,  which,  on  ac- 
count of  the  simpler  methods  of  technique  now  in  use,  both 
for  detecting  suitable  donors  and  for  the  actual  transfusion, 
has  now  come  into  widespread  use. 

Technique  of  Tests  for  Ilwmoli/sis  and  Agglutina- 
t'^m. — Lindeman's  ^*^  method  of  testing  the  suitability  of 
donors  is  as  follows:  "  The  red  blood-cells  of  patient  and 
donor  are  washed  three  times  with  normal  saline:  v -rying 

291 


1 


m 


f^] 


Ih'** 


292 


THE  SPLEEN  .VXD  AN.EMIA 


quantities  of  patient's  serum  are  placed  in  tliree  separate 
small  test-tubes.     To  each  of  these  are  added  0.2.)  c.c.  of 
a  2  per  cent,  suspension  of  washed  red  blood-cells  of  the 
donor.     The  same  is  done  with  the  donur's  serum  and  the 
patient's  cells.     Controls  are  made  of  donor's  serum  and 
donor's  cells — patient's  serum  and  patient's  cells.     Con- 
trols are  also  made  with  donor's  cells  in  normal  salt  solution 
and  ])atient's  cells  in  normal  salt  solution.     The  total  vol- 
ume in  each  tulx.-  is  raised  with  normal  saline  to  0.5  c.c.  of 
volume.     'J'he  test-tubes  are  incubated  in  a  water-bath  for 
a  period  of  two  hours,  and  readinirs  are  made.     Thev  are 
then  set  in  the  ice-box  over  ni^ht  and  readiiif^s  are  made 
again  the  following'  morning.     When  a  case  is  urgent,  the 
ice-box  test  is  eliminated.    The  ice-box  test  should  be  elimi- 
nated only  when  absolutely  necessaiy  by  the  extreme  con- 
dition of  the  patient,  where  time  is  the  important  factor. 
When  the  antount  of  blood  taken  from  the  patient  for  tests 
is  small,  only  0.-2.ji  c.c.  of  serum  is  used,  and  controls  of 
patient's  serum  are  eliminated."     A  Wassermann  test  of 
the    '  )nor's  blood  should,  whenever  j)ossible,  Ik?  included. 
This  and  the  subdivision  of  the  donor's   blood   into  the 
proper  a<>glutination  groups  may  readily  be  done,  if  the 
practice  is  followed  of  having  in  reserve  a  list  of  pros- 
pective donois  ready  to  donate  blmid  on  demand. 

In  1-tG  cases  in  which  tests  by  this  method  were  per- 
sonally sufjcrvised  by  Lindeman"not  a  single  case  of  ha-mo- 
lysis  and  not  a  single  death  referable  to  the  transfusion 
occurred.  The  necessity  for  careful  performance  of  the 
test  is  shown  by  the  fact  that  chills  occurred  in  only  thir- 
teen instances  (0  per  cent.),  whereas  in  nine  cases  in  which 
the  tests  were  not  personally  supervised  chills  occurred  in 
five  instances  {55  per  cent.)." 


TREATMENT  OF  SPLENIC  DISf^ASES 


9SS 


Minot  *"-  has  shown  that  if  one  has  on  hand  seruin 
and  corpuscles  of  subjects  belongin/r  to  Groups  II  and 
III  (of  Moss's  four  groups),  the  group  to  which  an  adult 
patient  belongs  may  be  detemiined  in  twenty  minutes.  If 
then  donors  are  available  that  have  been  previously  cata- 
logued according  to  groups,  transfusion  may  be  performed 
uitliout  danger. 

The  test  is  performed  as  follows :  A  suspension  of  red 
cells  from  the  patient  is  "  obtained  by  collecting  one  drop 
of  blood  in  about  1  c.c.  of  a  1.5  per  cent,  of  citrate  solution 
in  0.9  per  cent,  salt  solution."  A  drop  of  this  suspension 
is  mixed  separately  with  a  drop  of  each  serum  (which  re- 
tains its  agglutniating  power  for  months),  and  allowed  to 
stand  fifteen  or  twenty  minutes.  The  presence  or  absence 
of  agglutinr.tion  is  then  observed  microscopically.  Similarly 
;i  drop  of  the  patient's  serum  is  mixed  separately  with  a 
drop  of  suspension  of  corpuscles  known  to  belong  to 
xi roups  II  and  III,  and  treated  as  abo  e  described.  ^linot 
also  points  out  that  ha?molysis  does  not  always  occur  in 
vivo,  when  donor  and  recipient  belong  to  different  iso- 
agglutination  groups,  because  only  about  20  per  cent,  of 
s(Ta  that  are  agglutinative  are  ha?molytic.  Haemolysis, 
IiowcA-er,  never  occurs  without  being  preceded  by  or  asso- 
ciated with  agglutination.  "  Even  when  donor  and  patient 
Iiolong  to  the  same  iso-agglutination  group,  however,  there 
may  wcur.  after  transfusion,  reactions  of  unknown  nature, 
which  are  probably  of  not  so  severe  or  serious  a  nature  as 
lucmolysis." 

^Vhile  the  technique  of  the  various  methmis  of  trans- 
fusion now  in  use  cannot  be  considered  here,  suffice  it  to  say 
that,  with  proper  precautions,  untoward  accidents  may  be 
practically  eliminated  and  excellent  symptomatic  results 


rif  11 


r  .    J- 


'i 


294 


THE  SPLEEN  AND  ANEMIA 


usually  obtained.    In  all         chronic  an;pmias  under  con- 
sideration, not  only  is  t         cnjee  of  anasniia  greatly  les- 
sened after  transfusion,  l)ut  in  jjcmicious  anaemia  especially, 
a  bone-marrow  reaction,  similar  to  the  '■  blcKid  crisis  "  fol- 
lowing splenectomy,  is  apt  to  occur  four  to  ten  days  after 
transfusion.    Such  a  reaction  "  furnishes  the  most  favor- 
able time  to  do  a  splenectomy  in  those  cases  which  have 
been  transfused  in  preparation  for  the  operation"  (Vin- 
cent)*"'' and  frequc:>tly  initiates  in  pernicious  ana?mia  a 
remission  of  from  three  to  twelve  months.    It  might  then 
be  asked :  Why  not  continue  to  transfuse  instead  of  having 
recourse  to  a  major  operation  such  as  splenectomy?    Un- 
fortunately, (1 )  the  benefit  is  probably  of  shorter  duration 
than  ■■"  the  benefit  confened  by  splenectomy;  (2)  in  some 
cases  improvement  Ixjcomes  less  and  less  after  each  trans- 
fusion, and  (3)  the  increased  blood  destruction,  as  shown 
by  urobilin  excretion,  is  not  lessened  as  it  is  by  splenectomy. 
In  a  study  of  212  blood  transfusions  in  189  cases,  Otten- 
berg  and  Libman ''-'  discuss  at  length  the  various  condi- 
tions in  wliich  transfusion  is  indicated.    Although  the  best 
results  were  foimd  in  such  conditions  as  simple  hemorrhage, 
liemorrhagic  diatheses,  and  acute  poisoning,  improvement 
was  also  noted  in  various  infections,  debilitated  conditions, 
and  in  the  chronic  primary  anaemias.    In  twenty-five  trans- 
fused cases  of  pernicious  arifvmia,  "  fourteen  underwent 
more  or  less  prolf)nged  remissions  immediately  following 
transfusion,  and  eleven  showed  little  or  no  effect.     Of 
these  eleven,  three  were  moribund  at  the  time  of  trans- 
fusion and  died  within  a  few  hours  or  days.     The  other 
eight,  in  spite  of  marked  rise  of  haemoglobin  and  temporary 
symptomatic  improvement,  showed  no  interruption  in  the 
course  of  tlic  disease,  but  continued  to  show  blood  destruc- 


TREATMENT  OF  SPLENIC  DISEASES 


295 


tion  of  about  the  same  rate  as  before  transfusion.  Of  the 
fourteen  patients  who  showed  progressive  improvement 
following  one  or  more  transfusions,  one  had  a  remission 
lasting  approximately  three  months,  three  had  remissions 
lasting  six  or  more  months,  three  lasting  a  year  or  more, 
and  three  lasting  over  two  years."  In  spite  of  the  remis- 
sions that  are  known  to  occur  spontaneously  in  pernicious 
aiuemia,  a  record  such  as  the  above  leaves  but  little  doubt 
as  to  the  value  of  blood  transfusion  in  this  condition.  For- 
merly when  the  technique  of  whole  blood  transfusions  was 
difficult  single  large  doses  were  employed,  but  with  the 
simpler  methods  now  in  vogue  repeated  transfusions  of 
400  to  600  c.c.  are  considered  preferable  in  the  chronic 
ana?mias.  Xot  only  is  the  desired  amount  of  blood  easier 
to  obtain  and  the  discomfort  to  the  donor  lessened,  but  also 
the  danger  of  hypertransfusion  is  avoided  and  the  indi- 
cations about  as  well  met  as  when  larger  doses  are  used. 
As  many  as  fourteen  transfusions  have  been  employed 
with  benefit  in  chronic  conditions  (McClure  -'") .  It  must 
be  recognized  that  in  some  refractory  cases  the  later  trans- 
fusions in  a  series  have  done  more  good  than  the  earlier 
ones ;  but  it  is  usually  true  that  if  the  procedure  has  failed 
in  the  first  instance,  it  will  probably  continue  to  do  so  in 
the  future,  but  is  less  apt  to  do  so  if  a  different  donor  is 
used.  From  a  study  of  seven  cases  of  pernicious  anaemia 
which  had  been  splenectomized  and  later  transfused,  Vogel 
and  Downes  gained  the  impression  that  the  subsequent 
effects  of  transfusion  were  more  marked  and  persisted 
longer  in  such  cases  than  in  those  in  which  splenectomy 
had  not  been  perfonned. 

It  would  therefore  seem  that  in  pern'cious  anfemia,  if 
signs  of  increased  ha?molysis  are  present,   transfusions 


11 


f    .1 


..'ii 


290 


THE  SPLEEN  ^VXD  .VN.EMU 


'  .  i 


';?  'f 


should  be  eniployed  until  the  patient  is  in  the  best  condi- 
tion to  submit  to  splenectomy;  and  again  after  splenec- 
tomy, when  the  effect  of  the  operation  has  passed  away. 
If,  on  the  other  hand,  the  case  is  of  the  steadily  progressive 
type,  unsuitable  for  splenectomy,  transfusions  may  l)e 
employed  as  a  palliative  iiieasure,  according  to  the  state 
of  patient's  condition  and  purse.  In  the  various  "  indirect 
methods"  (syringe.  Erlenmeyer  flasks,  citrated  blood, 
etc.)  the  amount  ot  blood  transfused  can  be  accurately 
measured,  but  even  in  the  "  direct  "  methods  an  approxi- 
mate estimate  of  the  amount  of  blood  received  may  be 
obtained  by  accurately  weighing  the  patient  before  and 
after  transfusion, 

2.  Medicinal  and  Ili/gienir  Meamires. — Medicinal  and 
hygienic  measures  to  be  employed  in  the  treatment  of  the 
disea.ses  under  discussion  are  the  usual  remedies  for  anjemia, 
such  as  iron, arsenic  (salvarsan), improved  general  hygiene, 
and  an  ample  but  sim])le,  nutritious  diet.     Conflicting  re- 
sults have  been   reported   from  X-ray  treatment  of  the 
spleen,  but  it  is  possible  that  properly  graded  doses  may  be 
of  distinct  value.     It  is  almost  sujierfluous  to  add  that  in 
cases  of  splenomegaly  with  anaemia,  where  a  causative  factor 
sucii  as  malaria,  lues,  uncinariasis,  etc.,  is  known  to  exist, 
appropriate  medication  is  all-important.     Up  to  a  few 
years  ago,  l>efore  spk-nectomy  and  blood  transfusions  came 
into  vogue  in  the  treatment  of  chronic  an;pmia,  various 
medicinal  remedies  were  reported  as  of  value.     Organo- 
therapy   (spleen   and   bone-marrow   feeding,    Chauffard, 
Widal)  and  cholagogues  (Chauflard,  Cavazza"*),  proved 
of  but  bttle  help,  and  only  with  a  long-continued  course  of 
high  iron  diet  did  Widal  find  any  marked  improvement. 
On  account  of  the  antiha>molytic  properties  of  arsenic 


TREATMENT  OF  SPLENIC  DISEASES 


897 


iCiuiin  and  Felthaiu  "''"^),  cholesterin  (Chauffard  and  Gri- 
<;aut,'^  Parisot  and  Ileully  ^^'*),  and  calcium  chloride 
( Iscovesco  '■'*),  these  dru^s  have  been  tried,  in  some  cases 
uitli  considerable  improvement. 

On  the  whole,  however,  it  nmst  be  recognized  that  in  the 
s()-calle<l  priniarj'  anaemias  medicinal  t/eatment  is  at  best 
palliative,  and  in  most  cases  unsatif.factorj',  if  relied  upon 
for  more  than  a  short  period. 

ti.  Surgerij  other  than  Splenectomy. — A  few  surgical 
iiRasures  other  than  splenectomy  have  been  employed  in 
these  conditions,  but  may  be  dismissed  in  a  fe"v  words. 
Chauffard  and  Troisier,'*  Marchiafava  and  Xazari  ^'^ 
attempted  to  influence  ha?molytic  jaundice  by  various  sur- 
gical attempts  on  the  bile-passages,  but  their  failures  are 
to-day  only  of  historical  interest.  A  peculiar  operal  >n, 
designed  to  diminish  splenic  function  by  squeezing  the 
organ  in  new-formed  connective  tissue,  is  recommended  by 
Schiassi,^"''  under  the  term  "  splenocleisis,"  for  cases  in 
which  splenectomy  could  not  be  performed.  The  capsule 
of  the  organ  is  scarified,  and  wrapped  with  iodoform  gauze, 
which  is  later  gradually  witlidrawn.  Destruction  of  the 
spleen  by  gradual  cauterization,  after  fixation  to  the  ab- 
dominal wall,  has  also  been  suggested,  but  the  field  for 
such  a  procedure  would  seem  to  be  extremely  limited  and 
the  chances  of  s';c(  .;ss  not  very  great.  In  similar  cases 
Troell  **^  recommends,  on  the  basis  of  experimental  work 
similar  to  that  done  in  this  laboratory  (page  121),  ligation 
of  the  splenic  arteries  and  veins.  Lanz  '^'  found  ligation 
of  the  artery  beneficial  in  three  cases  of  wandering  spleen, 
but  Roblee  '*"  states  that  out  of  six  cases  in  which  ligation 
was  tried  by  Dr.  Skel  (discussion  of  Harris  and  Ilerzog's 
paper  *"),  four  died.    Although  there  is  no  theoretical  or 


H 


I  if 


4-. 


1     i.ta 


li 


'  i\ 


'.  ■mm\ 


298 


THE  SPLEEN  AND  AN^EMLV 


L 


experimental  reason  for  such  high  mortality,  this  operation 
must  still  be  considered  to  be  in  the  experimental  stage. 

The  most  promising  results  from  surgical  measures 
other  than  splenectomy  are  to  be  found  '  .  tiie  recent  studies 
of  Percy  '^^  on  tb.e  efl'ccts  of  removing  chronic  sources  of 
infection  in  cases  of  pernicious  anaemia  in  which  the  spleen 
is  also  removed.    lie  found  in  pernicious  an;emia  not  only 
that  chronic  inflammation  may  frequently  occur  in  the  gall- 
bladder, appendix,  and  other  organs,  as  well  as  in  and 
about  the  spleen  itself,  but  also  that  the  same  strains  of 
bacteria  may  freciuently  be  cultivated  both  from  the  spleen 
and  the  other  organ  or  organs  involved.    In  the  hope  that 
a  possible  cause  or  contributing  factor  to  pernicious  ana-mia 
may  thus  be  eliminated,  he  therefore  routinely  removed 
gall-bladder,  api)endix,  tonsils,  or  carious  teeth,  or  as  many 
as  showed  signs  of  chronic  infection,  either  simultaneously 
with  the  spleen  or  as  soon  thereafter  as  was  practicable. 
Even  the  energetic  treatment  of  a  complicating  pyorrha^ 
has  apparently  reinforced  the  improvement  caused  by  sple- 
nectomy.      Of   twenty-four   cases   treated   in    this'  way, 
twenty-one  showed  a  marked  postoperative  improvement,' 
and  fourteen  of  these  have  still  continued  in  their  improved 
conditions  over  periods  lasting  from  eight  to  thirty-one 
months.    In  view  of  these  excellent  results  and  as  long  as 
the  cause  of  pernicious  auc-emia  remains  unknown,  it  there- 
fore seems  highly  advisable  to  supplement  splenectomy  in 
this  condition   by  the  above   procedures  in   any   patient 
in   whom   such  signs  of  chronic   focal   infection  can   be 
demonstrated. 


..  {. 


CHAPTER  XIV 

TREATMENT:  VALUE  OF  SPLENECTOMY  AS  A    THER- 
APEUTIC PROCEDURE 

Splenectomy  for  rupture  or  severe  injurj-  of  the 
spleen  is  one  of  the  oldest  abdominal  operations  about 
which  we  have  definite  knowledge."''^  It  was  not  until  the 
advent  of  anaesthesia  and  the  greater  surgical  skill  of  the 
nineteenth  century,  however,  that  it  was  found  practicable 
to  remove  the  chronically  diseased  organ  and  thus  widen 
the  field  of  applicability  of  the  operation  beyond  that  of 
surgical  emergencies.  Unfortunately,  among  the  chronic 
diseases  of  the  organ  first  attacked  were  the  enlargements 
incident  to  cirrhosis  of  the  liver  and  leukemia.  The  un- 
favorable results  in  these  two  diseases  cast  discredit  upon 
the  operation ;  but,  nevertheless,  in  1 008,  Johnston  '^"^  was 
able  to  collect  708  cases  of  total  extirpation  of  the  spleen 
with  194  deaths.  From  1900  to  1908  there  were  355  cases 
with  66  deaths.  If  the  cases  of  leukemia  and  traimia  are 
subtracted,  the  list  is  reduced  to  235  cases  with  27  deaths, 
or  a  mortality  of  11.5  per  cent.  Since  1908  our  greater 
knowledge  of  the  physiolog\'  and  pathologj-  of  the  spleen 
has  resulted  in  a  better  selection  of  cases,  so  that  now  the 
total  mortality  has  been  somewhat  further  reduced  (Las- 
peyres,"^*  ^Slichelson,-""  Mayo^*-). 

In  the  past  three  years  a  more  active  study  of  the  sur- 
gical treatment  of  certain  so-called  primary  ana?mias  has 
led  to  the  much  more  general  use  of  splenectomy,  and  it  is 
this  application  of  splenectomy  that  attracts  most  attention 
at  present. 

209 


n| 


;     11] 


i    ia 


^d    I 


300 


THF  SPLEEN  AND  AN.i':MIA 


CoxTiLV-iNDicATioNS. — It  is  iiiost  important  to  know 
when  splenectomy  should  not  be  done.  We  now  know 
that  in  certain  diseases  removal  of  the  enlarj^ed  spleen  as  a 
curative  measure  is  contra-indicated.  These  include  the 
various  forms  of  Icuk.Tmia,  also  polycythjtmia,  and  most 
cases  of  malaria,  syphilis,  and  tuberculosis.  In  certain  cases 
of  cirrhosis  of  the  liver  (includin/r  the  hypertrophic  form) 
Eppiri^j^er  has  recently  advcK-ateri  splenectomy  on  account 
of  the  evidences  of  increased  blood  destruction  in  this  dis- 
ease when  jaimdice  is  a  prominent  feature;  but  in  the  ordi- 
nary atrophic  forms  in  the  absence  of  jaundice  the  desira- 
bility of  splenectomy  is  questionable.  Too  much  em^  ..jsis 
cannot  be  laid  on  the  necessity  of  ruling  out  atypical  forms 
of  leuka?mia — before  the  splenectomy  is  undertaken;  but. 
on  account  of  the  fijeat  variety  of  aleukftmic  cf)nditions. 
this  is  often  an  extremely  difficult  task.  In  no  case,  how- 
ever, should  splenectomy  be  advised  until  the  blood  picture 
has  been  carefully  studied  over  an  extended  period  of  time 
and  the  presence  of  leukaemia  excluded  so  far  as  may  be 
possible. 

Anything  pointing  toward  a  hemorrhagic  diathesis 
should  also  l)e  given  careful  consideration.  Its  presence  is, 
as  a  rule,  sufficient  to  contra-indicate  operation,  although 
the  repeated  hemorrhages  from  varices  or  due  to  other 
mechanical  causes,  as  in  Banti's  disease,  are  more  indica- 
tions for  operation  than  otherwise. 

In  the  severer  anaemias  definite  signs  of  bone-marrow 
activity  should  also  be  forthcoming  (nucleated  or  reticu- 
lated cells,  Jolly  bodies,  etc.) .  If  they  cannot  be  provoked 
by  appropriate  drugs  or  by  transfusion,  it  is  probable  that 
the  marrow  is  relatively  aplastic  and  splenectomy  should 
not  usually  be  attempted. 


SPLENECTOMY  TREATMENT 


301 


That  the  reinoval  of  tlie  iioriiial  spleen  is  followed 
hy  a  temporary  aiiieinia  has  heon  shown  both  by  cliiiieal 
observation  and  animal  experimentation;  but  this  should 
not  be  eonsidered  a  eontra-indication  to  operation.  The 
apparent  paradox  that,  while  removal  of  the  normal  spleen 
eauses  a  temporary  anaemia,  removal  of  the  spleen  in  eer- 
tain  bhwHl  disease?-,  relieves  the  existing  anaeniia,  has  been 
commented  upon  in  ancrther  section. 

I.kuk,i:mia. — On  account  of  the  almost  invariably  fatal 
outcome  of  splenectomy  in  early  cases  of  leuka>mia,  for 
some  decades  the  operation  has  been  considered  as  definitely 
contra-indicated  in  this  condition.     Occasional  cases  have 
been  reported,  however,  in  which  death  did  not  follow  sple- 
nectomy, and,  in  addition,  the  success  that  has  attended 
this  operation  in  recent  years  has  inevitably  tended  to  have 
the  procedure  applied  to  conditions  which  had  previously 
been  considered  unsuitable.     To  help  prevent  the  unwar- 
ranted inclusion  of  leukicmia  in  the  scope  of  splenectomy, 
some  evidence  is  here  furnished  as  to  the  result  hitherto 
obtained  in  this  condition.    In  1898,  Vanverts  "'  collected 
twenty-nine  cases  of  splenectomy  for  leukaemia,  to  which 
Fevrier'''  adds  two  more.     Of  the  thirty-one  cases,  only 
three  survived  the  operation.     Of  these  three  cases  there 
has  been  considerable  doubt  as  to  whether  Franzolini's  was 
really  a  case  of  leuka^nia,  and  Banti  did  not  hesitate  to 
call  it  a  case  of  Banti's  disease.    Burkhart's  case  was  appar- 
ently operated  upon  in  an  early  stage   (leucocyte  count 
about  43,000).     That  the  course  of  the  malady  was  not 
influenced  by  the  operation  is  shown  by  the  fact  that  the 
patient  died  eight  months  later  with  the  typical  physical 
signs  and  blood  picture  of  leuka?mia.     In  the  third  case 
(Hartmann's)   improvement  lasted  for  three  years,  but 


ji    SI 


30-2 


THE  Sl'LEKN  AM)  AN.KMIA 


emaciation  and  gingival  hcniorrhagt-s  then  became  appar- 
ent. Tlie  cause  of  dcatli  in  almost  every  unsuccessful  case 
is  hemorrliane,  wlietlier  from  the  pedicle  of  the  spleen,  from 
torn  adhesions  between  the  spleen  and  diaphrai^m,  viscera, 
or  parietal  wall,  or  from  the  laparotomy  wound.  In  the 
single  case  that  I  have  had  opportunity  to  examine,  an 
aleukcTmic  leuka'mia,  with  a  total  leucocyte  coimt  ranging 
from  lO.OUO  to  l.j.OOO,  but  with  myeloid  cells,  the  spleen 
was  removed  apparently  without  hemorrhage,  but  the  ab- 
dominal wound  showed  no  tendency  to  heal.  \  entral  hernia 
could  not  be  avoided,  and  the  patient  died  two  weeks  after 
operation  from  an  acute  generalized  peritonitis. 

In  a  few  cases,  where  the  great  size  of  the  spleen  or  a 
complication  such  as  extreme  mobility  lias  been  the  promi- 
nent symptom,  splenectomy  has  been  practised  as  a  pallia- 
tive measure.  Kuttner  - '^  reported  one  such  case  of  the 
n)yeh)genous  type  that  continued  to  improve  while  under 
observation,  but  he  recognized  that  the  progress  of  the  dis- 
ease had  not  in  any  way  been  influenced  by  the  procedure  in 
a  curative  sense.  On  account  of  the  high  postoperative  mor- 
tality and  of  the  evidence  that  the  course  of  the  disease  is 
not  affected  by  the  operation,  it  is  safe  to  say  that  splenec- 
tomy is  definitely  contra-indicated  in  the  various  fom\« 
of  leuka?mia.  This  is  especially  true  in  the  acute  form, 
while  in  the  more  chronic  forms  it  should  only  be  under- 
taken when  the  most  urgent  indications  are  present. 

PoLYCYTH.T.MiA  lluBRA. — On  account  of  the  fact  that 
polycj-thivmia  rubra  (erythnemia,  Vaquez's  disease)  is  the 
only  primary  disorder  of  the  red  blood-cell  system  in  which 
the  cell  count  is  increased,  and  that  splenectomy  has  been 
attempted  unsuccessfully  in  this  condition,  it  seems  advis- 
able to  consider  it  in  some  detail  at  this  point,  although  it 


SPLENECT«,...IV  TREATMENT 


303 


iWfi 


cannot,  of  (.'ourse,  be  included  anion^  the  univniias.  First 
described  by  \'a(iiiez  *'''  in  181>'J,  tliis  i)cculiar  syndrome 
was  later  brou^lit  more  prominently  before  the  niedical 
profession  by  Osier'-'  in  I'.X).'}.  and  its  various  features 
more  exhaustively  studied  by  Cominotti,"''  Ilirsehfeld,''" 
Senator,""  Abeles,"  :'nd  others.  Aceordin<f  to  Luten- 
bacher.  whose  monograph  and  bibli()<rraphy  present  the 
most  complete  study  of  this  disease,  the  salient  symptoms 
are  ( 1 )  a  tiiie  erythrosis  of  skin  and  mucous  membrane 
(  rather  than  cyanosis,  which  may  also  be  present) ,  ( -' )  dila- 
tation and  engorgement  of  the  veins  of  the  skin  and  retina, 
(3)  gastro-intestinal  disorders,  albuminuria,  vertigo,  head- 
ache, sonmolence,  and  lassitude  (all  <hie  to  visceral  ple- 
thora), (4)  pains  resembling  erythromelalgia,  (.5)  poly- 
globulia (up  to  nine  or  eleven  million  erythrocytes  per 
cubic  millimetre),  relative  increase  of  polymorphonuclear 
leucocytes,  with  attempts  at  medullary  reaction,  ((5)  en- 
largement of  the  liver  and  especially  of  the  spleen,  though 
these  features  are  not  a  necessarj'  part  of  the  syndrome. 
The  resistance  of  the  erythrocytes  to  various  ha>molytic 
agents  has  seldom  been  tested  in  polycythfemia.  In  most 
cases  it  has  been  found  to  be  normal,  although  Guinon, 
Rist,  and  Simon  ''®  reported  a  case  in  which  the  resistance 
to  hypotonic  salt  solutions  ^-^as  slightly  increased.  Pick- 
ard^^*  has  very  recently  described  a  case  of  true  poly- 
cythaemia  in  which  hemolysis  began  at  0.48  per  cent.  XaCl 
and  was  complete  at  0.30  per  cent.  XaCl  (essentially 
normal  limits) .  An  increased  resistance  to  a  different  kind 
of  ha?mol}'tic  agent,  on  the  other  hand,  was  shown  by  the 
fact  that  to  antihuman  hsemolytic  amboceptor  the  patient's 
cells  showed  no  ha?molysis  when  m'xed  with  twice  the 
amount  of  amboceptor  necessary  to  hjemolyze  normal  cor- 


I  gill 
J '11 


Hi 


S04 


THE  SPLEEN  AND  AN^^MIA 


1.; 


'  ,4 


i  ■'* 


puscles.  That  this  is  not  always  the  case  in  polycythemia, 
however,  is  shown  hy  the  findinjj^s  of  Freuiul  and  Rex- 
ford,'  "'•'  in  whose  ease  the  same  test  was  performed  and  tlie 
resistance  found  to  l)e  normal. 

The  ctiolo^'  is  completely  unknowTi,  though  it  is  proh- 
able  that  various  toxic  or  infectious  agents  may  provoke 
the  syndrome,  either  by  direct  marrow  stimulation  or 
through  excessive  repair  after  a  primary  red  blood-cell  de- 
struction. Thus  Belonowsky  was  able  to  raise  both  h;vmo- 
globin  and  er\thrm'yte  c(  int  by  the  frecjuently  repeated 
injection  of  minute  doses  of  luemolytic  serum.  In  true 
cases  it  is  possible  to  rule  out  all  mechanical  causes,  such 
as  occupation,  hypertension,  heart  and  lung  disease,  and 
adenopathy  and  other  alterations  in  the  blocxl  should  not 
be  present.  The  pathogenesis  of  the  disease  is  probably 
due  to  a  true  ])one-ntarrow  hyperplasia,  as  is  shown  by  the 
fact  that  the  over-active  bone-marrow  is  but  seldom  forced 
to  deliver  inmiature  or  nucleated  red  !)lood-cells  to  the  cir- 
culation. All  the  symptoms  can  be  explained  as  a  result 
of  this  plethora.  The  enlarged  spleen  is  largely  spodogen- 
ous;  i.e.,  compensatory  attempt  to  provide  for  excessiv-e 
blood  destruction,  with  resultant  increased  macrophagic 
action  and  congestion. 

On  a  priori  grounds,  therefore,  it  will  readily  be  seen 
why  splenec-tomy  should  not  be  undertaken  in  this  disease. 
If  it  is  correct  that  the  primary  trouble  is  in  the  hyper- 
plastic lione-marrow,  the  overactive  spleen  should  be  looked 
upon  as  the  chief  agent  to  keep  the  plethora  within  limits 
compatible  with  life.  A  logical  radical  treatment  woidd 
he  the  obliteration  of  the  marrow  of  one  or  more  long  bones, 
or  ligation  of  nutrient  arteries,  just  as  partial  excision  of 
the  thyroid  causes  improvement  in  exophthalmic  goitre. 


SPLENECTOMY  TREATMENT 


305 


mi 


Sach  procedure  has  not  to  my  knowledge  been  attempted, 
and  it  is  doubtful  if  a  sufficient  effect  could  be  produced 
to  make  it  of  clinical  value.  As  a  matter  of  fact,  sple- 
nectomy has  been  but  rarely  attempted,  although  Luten- 
bacher  states  that  "  it  has  been  followed  in  several  cases 
by  a  rapidly  fatal  termination  from  suppuration  or  hemor- 
rhage, and  in  those  cases  that  survived  it  has  caused  an 
evident  augmentation  in  the  polyglobulia."  A  confirma- 
tion of  the  protective  action  of  the  spleen  in  this  condition 
is  afforded  by  the  increase  in  polycythsemia  in  cases  where 
enlarged  spleen  has  been  reduced  in  size  by  X-ray  treat- 
ment. In  some  cases,  on  the  con*  'arj'  (perhaps  where  the 
X-ray  dosage  to  the  spleen  has  been  irritative  rather  than 
destructive) ,  this  form  of  treatment  has  proved  beneficial. 
Destructive  X-ray  applications  to  the  long  bones  have  not 
proved  of  value.  Large  venesections,  repeated  at  rare 
intervals  and  followed  by  salt-solution  injection,  have  also 
been  of  use  in  some  cases,  but  the  consequent  improvement 
is  always  evanescent  and,  on  the  whole,  this  treatment  must 
be  considered  unsatisfactory. 

Diseases  in  Which  Spleneci'omy  May  Occasionally 

BE  Indicated 

Cirrhosis  of  the  Liver. — Mention  has  already  been 
made  of  the  fact  that  Eppinger  had  presented  an  experi- 
mental basis  for  extending  splenectomy  to  cases  of  cirrhosis 
in  which  jaundice  was  a  chronic  and  prominent  symptom. 
On  account  of  the  enlargement  of  the  spleen  that  fre- 
quently is  found  at  an  early  stage  of  cirrhosis  of  the  liver, 
Kppinger  *"*  was  led  to  search  for  evidences  of  increased 
blood  destniction  in  this  connection  also.  This  was  forth- 
coming, when  jaundice  was  present,  not  only  in  the  exist- 

20 


a 


J 


i 


LI ,. 


J  ■: 


306 


THE  SPLEEN  A^F  AIs^MIA 


l.'U    ' 


ence  of  increased  aiiEemia,  but  also  in  the  increased  amount 
of  urobilin  found  in  the  stool  and  the  high  iodine  number 
of  the  blood.  With  less  justification,  but  on  account  of 
the  analog}'  that  exists  between  the  changes  in  the  liver 
and  spleen  in  portal  cirrhosis  and  in  Banti's  disease,  other 
authors  have  attempted  splenectomy  in  portal  cirrhosis 
even  in  the  absence  of  jaundice  or  other  signs  of  excessive 
blood  destruction.  Thus  Jullien,-*"  in  1911,  reports  seven 
cases  treated  in  this  way,  of  which  two  died  as  a  result  of 
the  operation,  while  the  others  showed  considerable  im- 
provement. This  even  included  such  important  changes 
as  the  long-continued  disappearance  of  a  chronic  ascites, 
and  of  the  superficial  evidences  of  collateral  circulation. 
Kidd^^'  believes  that  splenectomy  should  be  tried  in  all 
cases  of  cirrhosis  showing  enlargement  of  the  spleen,  and 
W.  J.  iVIayo^'  has  also  found  splenectomy  advisable  in 
cirrhosis  of  the  liver.  In  addition  to  one  case  of  Hanot's 
cirrhosis  in  which  the  spleen  was  removed  with  "  undoubted 
benefit  and  possible  cure,"  he  has  removed  the  greatly- 
enlarged  spleens  from  four  patients  suffering  from  portal 
cirrhosis.  Although  it  was  too  early  to  know  whether  or 
not  the  end  results  had  justified  the  operation,  three  of 
the  four  patients  showed  marked  improvement  with  dis- 
appearance of  the  a,scites  and  anaemia.  Although  the  evi- 
dence is  still  meagre  on  this  point,  and  the  evidence  at  hand 
insufficient  to  determine  what  types  of  cirrhosis  are  in- 
cluded under  this  term  by  surgeons,  the  results  are  favor- 
able enough  to  entitle  the  procedure  to  further  considera- 
tion. In  estimating  their  value,  however,  it  should  be 
remembered  that  the  differential  diagnosis  of  portal  cir- 
rhosis from  Hanot's  cirrhosis  and  from  Banti's  disease 
and  other  similar  conditions  is  often  difficult  or  impossible 


SPLENECTOMY  TREATMENT 


307 


to  make,  and  it  should  also  be  borne  in  mind  that  there  is 
removed  with  the  spleen  a  reservoir  which  to  some  author- 
ities is  of  great  importance  in  accommodatinfr  the  blood 
which  accumulates  behind  the  obstacle  of  the  cirrhotic  liver. 
Whether  or  not  this  very  accumulation  of  blowl  in  the 
spleen  is  a  factor  which  may  lead  to  increased  blood  de- 
struction is  a  point  for  the  future  to  decide. 

M.vi^vRiA  AND  Syphilis. — The  extreme  size  attained  by 
the  spleen  in  chronic  malaria  and  the  frequency'  of  malaria 
in  tropical  regions  early  turned  the  attention  of  French 
and  Italian  surgeons  toward  the  advisability  of  splenec- 
tomy in  this  condition.  In  spite  of  almost  uniformly  fatal 
results  in  the  early  cases,  surgeons  have  persisted  in  their 
attempts,  on  account  of  the  many  distressing  symptoms 
(dyspnoea,  cyanosis,  vomiting,  dysiiria,  dysmenorrhnea, 
abdominal  pain,  etc.)  that  the  tremendously  enlarged 
spleen  may  cause.  The  operation  has  been,  however,  at- 
tended with  unusual  difficulties  on  account  of  the  friability 
of  the  organ  and  vessels  and  the  great  number  and  density 
of  the  adhesions  in  most  cases.  This  not  only  promotes 
the  liability  to  severe  hemorrhages,  but,  on  accoinit  of  the 
length  of  time  required  for  the  operation,  greatly  increases 
the  shock  of  the  operation.  Of  the  twelve  deaths  in  the 
series  of  forty-seven  cases  collected  by  Olgiati,'''^'  ten  were 
due  to  these  causes,  the  other  two  to  peritonitis.  Twenty 
of  the  thirty-five  cases  that  recovered,  on  the  other  hand, 
had  ectopic  spleens,  which,  therefore,  did  not  present  ad- 
hesions to  the  surrounding  organs.  As  it  is  precisely  this 
type  of  spleen  that  is  especially  liable  to  the  further  com- 
plication of  torsion  of  the  pedicle  and  rupture,  exploratory 
lap.irotomy  would  be  indicated  if  the  enlarged  spleen  had 
failed  to  respond  to  medicinal  treatment  and  was  causing 


]■ 


308 


THE  SPLEEN  AND  AN/EMIA 


'  ,  ) 


distressing  symptoms.  It  should,  however,  be  recognized 
that  splenectomy  was  undertaken  for  the  relief  of  such 
symptoms  ami  not  as  a  curative  measure.  In  Roumania 
splenectomy  has  been  practised  in  resistant  cases  of 
chronic  malaria  with  considerable  improvement  in  many 
cases,  but  with  the  high  operative  mortality  of  over  twenty 
per  cent.  (Racoviceanu '"'").  As  all  these  figures,  how- 
ever, date  from  more  than  fifteen  years  ago,  the  better  tech- 
nique of  the  surgery  of  to-day  may  eliminate  shock  and 
hemorrhage  to  such  a  degree  that  the  mortality  in  malaria 
may  prove  to  be  no  higher  than  in  the  other  diseases. 

In  some  cases  of  long-standing  syphilis,  also,  when  the 
enlarged  spleen  has  proved  resistant  to  specific  treatment, 
it  may  be  advisable  to  remove  the  organ  that  has  become 
the  chief  cause  of  the  patient's  disability.  Thus  W.  J. 
Mayo^*^  has  removed  the  greatly-enlarged  spleen  from 
three  patients  suffering  from  chronic  syphilis  and  marked 
ana?mia.  "  In  one  of  these  specific  treatment  had  been 
carried  out  for  two  years,  in  another  for  six  months,  with- 
out satisfactory  improvement  in  the  general  condition  of 
the  ana-mia.  Following  splenectomy,  there  was  marvellous 
improvement  of  the  anaemia  in  all  of  them." 

The  ultimate  results  of  splenectomy  in  such  cases  will 
be  awaited  with  great  interest.  It  may  prove  that  occa- 
sionally the  enlarged  spleen,  at  first  protective,  eventually 
assumes  a  pernicious  activity,  or  that,  like  the  central  ner- 
vous system  in  some  chronic  infections,  it  may  become  a 
secluded  nidus  of  infection  which  cannot  be  reached  by 
ordinary  medical  treatment.  In  either  of  such  contin- 
gencies its  removal,  therefore,  may  become  desirable. 
Nevertheless,  for  the  present  at  least,  enlarged  spleens 
sliould  only  be  routinely  removed  in  those  cases  where  the 


SPLENECTOMY  TREATMENT 


309 


indications  liave  been  proved  to  be  favorable  or  else  where 
sudden  emergencies  require  a  greater  latitude  in  the  em- 
ployment of  this  form  of  treatment.  The  widespread  re- 
moval of  spleens  without  accurate  diagnosis  or  regard  to 
the  suitable  indication.'^  will  undoubtedly  lead  not  only  to 
many  disastrous  results  but  also  to  the  indefinite  obscura- 
tion of  the  proper  field  for  this  important  operation. 

TABLE  LXIV 
Collected  Reports  of  Resulis  ok  iSPLENECTOMT  in  Vabiocs  Diseases  of 


THE  Blood 

Duease 

Autho.' 

Number 
of  caaes 

Uecov- 
ered 

Died 

Per  cent, 
mortality 

Gaucher  "s 

Erdman    and   Moor- 
head  '« 

Krumbhaar    

Elliott  and  Kanavel"" 

ElUott  and  Kanavel"" 

Elliott  and  Kanavel"" 

Stillman  *'^ 

10 

183 
16 

23 

9 

6 
153 

8 

155 
15 

22 

9 

6 
123 

2 

28 

1 

1 

0 

0 
30 

20 

15.4 
6.2 

4.3 

0 

0 

IJanii's 

Ha'inolytic  icterus  ac- 
quired 

Hajmoly  tic  icterus,  con- 
Rcnital  and  familial 

Hiemolytic  icterus,  un- 
cla.<<aified 

V.  Jalcfch's 

Pernicious  anxmia. . .  . 

Krumbhaar 

19  6 

DisE,\SEs  IN  Which  Splknectomy  is  Indicated 

In  certain  types  of  clironic  ansemia,  splenectomy  has 
met  with  considerable  success;  as  in  Banti's  disease,  Gau- 
clier's  disease,  the  congenital  and  acquired  forms  of  hiemo- 
lytic jaundice,  and,  to  a  lesser  extent,  pernicious  aiijcmia. 
The  cause  of  the  improvement  or  cure  that  follows  splenec- 
tomy in  these  conditions  is  but  incompletely  understood, 
and  is  probably  different  in  the  various  diseases  men- 
tioned. Some  of  the  factors  at  work  have  been  tcmsidered 
elsewhere  in  this  book. 

Banti's  Dise.\se. — In  Banti's  disease  it  is  important 
that  the  operation  should  be  undertaken  before  the  disease 


J 


1 

S^j^Hi 

1 

1 

1 

■1 

i^Hi 

SIO 


THE  SPLEEN  AND  AN^ML\ 


I 


3i 


has  progressed  beyond  the  first  stage.  Splenectomy  in  the 
first  stage  is  not  only  accompanied  by  a  lower  mortality, 
but  in  the  great  majority  of  cases  has  caused  great  and 
lasting  improvement  in  symptoms,  often  amounting  to  a 
complete  cure.  When  the  third  stage  is  reached,  with  per- 
manent changes  in  the  liver  and  circulatory  system,  not  only 
is  the  operation  more  dangerous,  but  the  chances  of  im- 
provement are  greatly  lessened.  As  a  result  of  the  disease 
process,  the  spleen  has  by  this  time  become  largely  fibrotic, 
and  its  removal  could  hardly  be  expected  to  be  attended 
with  marked  beneficial  effect. 

In  1907  Torrance  collected  thirty-six  cases  of  Banti's 
disease,  of  which  nine  died  as  a  result  of  the  operation,  a 
mortality  of  25  per  cent.  A  year  later  Johnston  added 
twenty-five  cases  with  only  three  deaths,  making  an  opera- 
tive mortality  of  reported  cases  up  to  1908  of  19.7  per  cent. 
By  a  far  from  exhaustive  survey  of  the  literature  since 
1908  we  have  added  122  cases  with  sixteen  deaths  that  were 
not  in  Torrance's  or  Johnston's  lists,  making  a  total  of 
183  cases  with  twenty-eight  deaths — a  mortality  of  15.4 
per  cent.  If  the  cases  since  1910  are  considered,  how- 
ever, there  are  found  76  cases  with  eight  deaths,  a  mortality 
of  only  11.1  per  cent.  Although  allowance  must  be  made 
for  the  more  liberal  publication  of  favorable  results,  this 
last  percentage  is  the  same  as  that  for  the  largest  collection 
from  any  one  clinic  (Mayo)  and  is  probably  very  close  to 
the  present  operative  mortality  for  this  condition.  With 
proper  selection  of  cases  and  technique,  ISfayo  believes  that 
this  mortality  percentage  can  still  be  cut  in  half.  On 
account  of  the  early  reporting  of  most  cases  it  is  impos- 
sible to  get  an  adequate  idea  of  the  ultimate  outcome  of 
cases   surviving  operation.     Occasional   reports  can  be 


SPLENECTOMY  TREATMENT 


Sll 


found  in  which  a  marked  postoperative  improvement  was 
followed  in  one  or  two  years  by  subsequent  relapse  or 
death  (Roberts/"  Lett,'^"  Kidd,^"  Giffin"").  Never- 
theless, the  prevalent  opinion  is  probably  correct  that  the 
improvement  that  follows  splenectomy  in  early  Banti's 
disease  in  the  great  majority  of  cases  either  amovmts  prac- 
tically to  a  complete  cure  or  persists  without  relapse  for 
many  years.  Even  in  the  third  stage,  splenectomy  may 
be  of  value:  thus  of  the  twenty  cases  of  this  series  that 
were  operated  upon  in  the  third  stage,  ascitic  or  cirrhotic 
stage,  five  succumbed  to  the  operation  and  at  least  three 
more  were  not  materially  helped  and  died  within  a  few 
years.  While  these  figures  are  less  encouraging  than  those 
for  the  earlier  stages,  they  by  no  means  should  be  taken  as 
proof  that  the  operation  is  contra-indicated  in  this  stage. 
As  early  as  1906,  Jaife  '*^  showed  that,  even  with  marked 
ascites  and  advanced  cirrhosis,  splenectomy,  if  combined 
with  the  Talma  operation,  may  be  attended  with  very  strik- 
ing improvement. 

A  patient,  then,  with  the  symptoms  of  Banti's  disease, 
particularly  if  in  the  early  stages  of  the  disease,  should  be 
considered  a  proper  subject  for  splenectomy,  but  the  most 
favorable  time  for  operation  should  be  selected.  Before 
undertaking  the  operation  all  other  possible  causes  for  such 
a  syndrome  {e.g.,  aleukasmia,  leuka?mia,  tuberculosis,  ma- 
laria, syphilis,  etc.)  should  be  ruled  out  so  far  as  possible 
by  a  complete  but  not  unnecessarily  prolonged  investiga- 
tion as  to  the  cause  of  the  disease,  through  frequently  re- 
peated blood  examination.  In  the  third  or  ascitic  stage  a 
combination  of  splenectomy  with  the  Talma  operation  is 
advisable. 

Gaucher's  Disease. — On  account  of  the  rarity  of  this 


5   i 


-:  il 


312 


THE  SPLEEN  AND  ANEMIA 


^,- 


I; 


condition  and  the  difficulty  of  diagnosis  without  the  aid  of 
histological  examination,  not  many  cases  are  available  for 
study.  In  1914,  P>dmann  and  Moorhead  ""'  collected  ten 
cases  of  large-celled  splenomegaly  (Gaucher's  disease)  in 
which  the  spleen  had  been  removed,  and  of  these,  two  died, 
both  within  twenty-four  hours  of  operation.  While  this 
probably  represents  too  high  a  mortality,  the  improvement 
which  followed  in  the  other  eight  cases  cannot  always  be 
taken  as  indicative  of  eventual  cure,  for  the  disease  is 
known  to  exist  independently  in  the  bone-marrow  and 
lymph-nodes.  It  would  therefore  seem  wiser  to  restrict 
splenectomy  in  this  disease  to  those  cases  that  are  unusually 
handicapped  by  the  results  of  the  disease,  but  are  still  good 
surgical  risks,  and  in  such  cases  to  limit  the  prognosis  to 
improvement  and  not  to  promise  complete  cure. 

H^i:molytic  Jaundice. — The  field  in  which  splenec- 
tomy has  been  practised  with  the  greatest  success  is  un- 
doubtedly that  of  ha?molytic  jaundice.  Both  in  the  ac- 
quired form  (Hayem-Widal)  and  the  congenital  or  fa- 
milial type  (ChauflTard- Minkowski),  marked  improvement 
and  frequently  complete  cure  have  resulted  from  removal 
of  the  spleen.  In  fact,  the  success  obtained  in  this  type  of 
case,  where  the  chief  vitium  is  that  of  increased  blood  de- 
struction, has  been  a  powerful  incentive  toward  extending 
the  operation  of  splenectomy  to  the  wider  range  of  allied 
diseases  discussed  in  this  chapter.  Splenectomy  was  first 
tried  in  this  condition  by  Vaquez  and  Giroux.  As  their 
case,  however,  died  two  days  after  operation,  ChaufFard's 
dictum  that  hsemolytic  jaundice  constituted  a  "Noli  me 
tangere  "  for  the  surgeon  prevailed  for  several  years.  In 
1911,  however,  splenectomy  was  again  tried  in  hfemolytic 


SPLENECTOMY  TREATMENT 


S13 


jaundice  with  a  very  different  result  from  that  in  Vavquez 
and  Giroux's  case.     In  that  year  Micheli  removed  the 
spleen  from  a  case  of  the  acquired  type  with  the  most  strik- 
ing improvement:  the  blood  count,  which  had  been  between 
980,000  and  2,600,000,  quickly  rose  to  almost  normal,  the 
acholuric  jaundice  and  urobilinuria  disappeared,  the  fra- 
gility of  the  red  cells  was  lessened,  and  the  patient  within 
a  few  months  was  apparently  cured.     Similar  beneficial 
results  were  obtained  by  Banti  in  his  two  cases  of  hjemolytie 
splenomegaly,  which  we  have  taken  to  be  identical  with  the 
acquired  form  of  haemolytic  jaundice.     Success  was  ob- 
tained in  other  early  operations  (Kahn,  Roth),  and  the 
procedure  would  undoubtedly  have  been  in  more  frequent 
and  intelhgent  use,  in  this  country  as  well  as  Europe,  if 
the  xmfortunate  grouping  of  several  clinical  entities  under 
the  cloak  of  "  Splenic  anaemia  "  had  not  clouded  the  worth 
of  the  procedure.    In  1915,  Elliott  and  Kanavel  ^'^'-  were 
able  to  collect  forty-eight  cases  of  haemolj-tic  jaundice  (six- 
teen acquired,  twenty-three  familial,  and  nine  unclassified) 
that  had  been  treated  in  this  way.    Of  the  forty-eight  cases, 
only  two  died — one  shortly  after  operation,  the  other  from 
sepsis,  six  weeks  after  operation.    The  other  forty-six  are 
reported  as  "cured,"  this  result  being  based  upon  the 
disappearance  of  jaundice  and  exacerbations,  and  decrease 
of  the  amemia  and  the  urobilin  excretion.    The  effect  on 
the  resistance  of  the  red  cells  was  not  constant;  in  some 
instances  the  resistance  returned  almost  to  normal,  but  in 
most  cases  the  red  cells  remained  almost  as  fragile  as  before 
operation.    In  spite  of  these  brilliant  results,  however,  it 
nmst  be  remembered  that  the  primary  cause  of  the  disease 
is  unknown  and  is  pi'obably  not  in  the  spleen.    The  case 


■n 


\  i 


V 


814 


THE  SPLEEN  AND  ANJiMIA 


i' 


reported  by  W'hipham  *'''  emphasizes  this  point;  although 
splenectomy  was  followed  by  great  clinical  improvement, 
return  of  the  red  blood-cell  count  to  a  level  above  normal 
(polyglobulia)  and  a  reduction  of  their  fragility  to  a  nor- 
mal level,  nevertheless,  three  montlis  after  operation, 
jaundice  and  extreme  anaemia  returned  and  the  child  died 
in  a  "  crisis  of  deglobulization."  "  Whatever  the  catua 
causorum,  it  must  be  regarded  as  established  that  it  is 
throurh  the  instrumentality  of  the  spleen  that  pathologi< 
hiemo  ysis  is  wrought." 

V.  Jaksch's  Disease. — The  results  of  splenectomy  in 
V.  Jaksch's  disease  are  too  meagre  to  be  of  value.  Only 
six  cases  have  so  far  been  reported  (Stillmann*'^*),  and, 
although  all  of  these  were  improved  by  the  operation,  it 
must  be  admitted  that  ptediatrists  claim  even  greater  im- 
provement or  even  cure  after  long-continued  medical  treat- 
ment of  this  condition.  It  should  be  noted  that  the  first 
case  reported  by  Stillmann  exhibits  certain  features  more 
compatible  with  the  diagnosis  of  ha?molytic  jaundice  than 
of  v.  Jaksch's  disease  (decreased  resistance  of  erythrocytes, 
great  increase  in  reticulated  en,i:hrocytes,  and  a  practically 
normal  leucocyte  coimt) . 

Pernicious  Ax^timia. — The  most  important  disease, 
from  the  point  of  view  of  its  greater  frequency  and  greater 
severity,  to  which  splenectomy  has  been  applied  is  per- 
nicious an.Emia.  The  striking  improvement  that  has  been 
shown  to  follow  removal  of  the  spleen  in  such  diseases  as 
hsemolytic  jaundice  and  Banti's  disease  naturally  led  to 
an  extension  of  this  clinical  procedure  to  allied  conditions. 
Tn  1913  three  investigators — Eppinger,*"*  Decastello,"' 
and  Klemperer,'^*® — working  independently,  tried  splenec- 
tomy as  a  therapeutic  measure  in  pernicious  anaemia.   It 


SPLENECTOMY  TREATMENT 


315 


is  interesting  that  Eppinger  was  led  to  adopt  this  pro- 
cedure by  observing  after  splenectomy  a  diminished  output 
of  urobilin  and  other  evidences  of  decreased  haemolysis. 
Decastello,  on  the  other  hand,  had  noted  the  improvement 
that  followed  splenectomy  in  the  related  conditions,  hfcmo- 
lytic  jaundice  and  Banti's  disease;  whereas  Klemperer  was 
influenced  by  the  clinical  observation  that  splenectomy  for 
such  conditions  as  rupture  of  the  spleen  was  in  some  in- 
stances eventually  followed  by  polycytlia?mia. 

Such  marked  improvement  was  noted  in  these  earlier 
cases  that  the  procedure  was  quickly  and  widely  repeated, 
chiefly  in  Germany  and  in  this  countrj%  so  that  a  fairly 
large  group  has  already  become  available  for  study.  More 
prolonged  observation,  however,  has  shown  a  considerable 
mortality  from  the  operation  and  postoperative  complica- 
tions, and,  moreover,  thai  very  few  of  the  patients  con- 
tinue steadily  to  improve;  in  almost  all  the  characteristic 
blood  picture  of  pernicious  anaemia  remained,  and  not  a 
few  died  from  relapses  of  the  disease  in  the  first  year  or  two 
after  operation.  The  object  of  this  section  is  to  show  by 
a  correlation  of  the  published  reports,  with  later  informa- 
tion obtamed  by  personal  communication,  just  how  valu- 
able splenectomy  has  thus  far  proved  to  be  in  pernicious 
anaemia.'^'"* 

Although  it  has  been  impossible  to  get  additional  re- 
ports from  some  of  the  German  authors,  and  of  some 
patients  who  have  been  lost  sight  of,  nevertheless  tiie  re- 
sults obtained  in  the  last  two  and  one-half  years  are  suffi- 
ciently concordant  to  give  evidence  of  some  value.  In 
drawing  conclusions  from  any  such  review,  however,  it  must 
be  remembered  that  certain  difficulties  are  unavoidable. 
For  instance,  the  dividing  line  between  pernicious  anaemia 


916 


THE  SPLEEN  ASD  AN^.ML\ 


i::;? 


i ' 
«■• 


and  some  of  the  other  primary  hlood  diseases  is  necessarily 
such  a  shadowy  one  that  the  possil)ihty  of  an  incorrect 
diagnosis  must  always  he  borne  in  mind.  Then,  too,  the 
concept  of  pernicious  ana-mia  varies  so  nuicli  witli  different 
authorities  that  cases  included  as  such  by  one  author  miglit 
easily  be  rejected  by  another.  Thus  one  of  the  earlier 
cases  of  splenectomy  that  was  followed  by  marked  and 
long-contitmetl  improvement,  when  sul)jected  to  critical 
analysis,  seems  to  be  ratlier  a  case  of  acijuired  lucmolytic 
jaundice  than  of  tnie  pernicious  ana-mia.  In  another  case 
reported  as  pernicious  anicmia  the  diagnosis  was  later 
changed  to  ha>molytic  jaundice  on  account  of  the  subse- 
quent appearance  of  acholuric  jaundice  with  diminished 
resistance  of  the  er\i;hrocytes.  As  such  variations  in 
diagnosis  are  apt  to  include  less  serious  diseases  under  the 
head  of  "  pernicious  ana-mia,"  or  diseases  in  which  sple- 
nectomy is  already  known  to  be  of  benefit,  the  present  sta- 
tistics will  be  correspondingly  favored  by  such  inclusions. 
In  applying  the  pn  -ent  figures  to  prognosis,  however,  it 
is  fair  to  oflt'set  the  iiu  lusiori  of  such  cases  with  the  results 
that  must  inevitably  follow  the  l)etter  selection  of  cases 
and  better  preparation  for  operation.  A  third  considera- 
tion is  that  the  terni  "  pernicious  anicmia  "  may  later  be 
found  to  include  m.oic  than  one  clinical  entity.  (CoMipare 
the  great  variations  that  occur  in  the  size  of  the  spleen, 
in  the  bone-marrow  reactions,  in  the  evidences  of  ha?mol- 
ysis,  and  in  the  duration  of  the  disease.)  If  this  were 
found  to  be  true,  it  might  well  be  that  some  of  the  appar- 
ently discordant  results  that  have  been  observed  after  sple- 
nectomy are  due  to  the  fact  that  the  operation  was  of 
value  in  one  or  more  types  and  contra-indicated  in  the 
others.  The  results  of  these  studies  are  included  in 
Table  LXV. 


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Analym  of  Results.— It  will  be  seen  that  of  the  i  S8 
individuals  whose  spleens  were  removed,  thirty  died  within 
six  weeks,  presumably  from  the  effects  of  the  operation,  a 
mortality  of  19.6  per  cent.  Of  the  remaining  123  patients, 
all  but  twenty-four  showed  a  distinct  improvement,  both 
in  general  condition  and  in  blood  picture.  Of  the  twenty- 
four  individuals  that  survived  the  operation  but  failed  to 
improve,  a  few  were  obviously  harmed  by  it.  To  this 
group  l)elongs  Pappenheim's  case,  splenectomized  at  a 
favorable  time,  when  the  patient  was  in  tlie  stage  of  a  re- 
mission. The  condition,  nevertheless,  was  aggravated  by 
the  operation:  the  blood  showed  signs  of  increased  destruc- 
tion and  a  serious  relapse  began.  The  improvement  noted 
in  the  majority  of  cases  lasted  var>-ing  periods.  Thus  at 
the  end  of  six  months,  of  fifty-three  patients  who  had  sur- 
vived operation  for  more  than  six  weeks  and  were  still 
under  observation,  forty-four  ht^a  still  continued  to  im- 
prove and  none  had  died,  but  nine  had  already  relapsed. 

TABLE  LXVI 
Late  Results  Aftek  Splenectomy  in  Pernicious  Anemia 


Number  oases  known 

Still  improved 

Relapsed 

Died  subsequently.  . 


After  one 

After  two 

year 

years 

27 

6 

11 

3 

7 

2 

9 

1 

At  the  end  of  the  first  year  after  operation  there  re- 
mained twenty-seven  patients  who  were  still  under  ob- 
servation (see  Table  LXVI ) .  Of  these,  Uecastello's  series 
is  the  most  important,  not  only  because  he  and  Eppinger 
were  che  first  to  try  this  procedure  and  therefore  the  cases 
oould  be  followed  for  a  longer  time,  but  because  the  early 


SPLENECTOMY  TREATMENT 


319 


successful  results  have  been  greatly  modified  by  time.  Of 
six  patients  at  the  time  of  his  publication,  several  months 
after  operation,  four  showed  such  great  improvement  that, 
except  f(-r  the  microscopic  appearance  of  the  blood,  they 
might  have  almost  been  considered  cured.  Two  years  later, 
however,  two  were  dead  and  one  was  in  as  poor  condition 
as  before  operation.  Of  the  other  two  important  early 
series,  Eppinger's  and  Klemperer's,  it  has  been  impos- 
sible to  get  additional  information.  The  figires  for  the 
whole  group  of  twenty -seven  cases,  however,  show  that  the 
initial  improvement  has  been  maintained  in  less  than  half 
of  the  cases. 

A  small  but  interesting  group  is  formed  by  six  indi- 
viduals ( see  Table  LX VI )  that  have  been  knovm  to  have 
lived  two  years  or  more  after  operat-on  (Descatello  [two], 
iffin,  Harpole,  Huber,  Thayer;.  Of  these,  Giffin's 
patient  haH  had  the  disease  for  two  and  one-half  years; 
the  anamiia,  was  not  extreme  at  the  time  of  the  operation, 
and  the  spleen  was  much  enlarged  ( 1640  gm. ) .  Improved 
by  the  operation,  he  died  three  years  later  from  pneumonia. 
In  Decastello's  two  cases  the  disease  had  existed  for  less 
than  a  year;  the  anaemia  was  severe  and  the  spleen  but 
slightly  increased  in  size.  These  patients  improved  after 
operation  both  chnically  and  as  to  the  blood  picture ;  but, 
whereas  one  in  a  subsequent  report  was  in  poor  condition, 
the  other  was  without  symptoms,  although  the  blood  picture 
was  still  that  of  pernicious  ana?mia.  Harpole's  patient  was 
known  to  have  had  pernicious  anir  \a.  for  two  years,  and 
at  the  time  of  operation  the  ameo)'  was  moderately  severe 
and  the  spleen  twice  the  normal  si/e.  After  splenectomy 
there  fK^curred  immediately  an  active  bone-marrow  re- 
action with  marked  clinical  improvement.    The  patient  has 


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continued  in  fair  health,  with  only  a  slight  anaemia,  hut 
with    persistence    of    spinal-oord    symptoms.      Ruber's 
patient,  who  was  considered  moribund  at  the  time  of  opera- 
tion, improved  rapidly  for  seven  weeks,  relapsed,  and  later 
underwent  a  spontaneous  remission.    After  two  and  one- 
half  years  she  was  still  in  good  condition  and  able  to  do  her 
housework,  but  still  anaemic.     Thayer's  patient,  having 
had  the  disease  one  year,  improved  after  splenectomy, 
although  there  was  no  bono-marrow  reaction.    After  eight- 
een months  the  patient  relapsed  to  the  same  condition 
as  before  operation  and  was  last  reported  in  poor  condition. 
Estimation  of  the  value  of  such  a  procedure  as  splenec- 
tomy in  pernicious  anaemia  must  take  into  consideration 
not  only  the  actual  results  obtained,  but  a  comparison,  so 
far  as  is  possible,  with  the  probable  results  if  operation 
had  not  been  undertaken.     Thus,  whereas  we  have  seen 
that  splenectomy  caused  a  quick  and  marked  improvement 
in  64  per  cent,  of  all  patients,  natural  remissions  occurred 
at  one  time  or  another  in  over  80  per  cent,  of  the  pa,tiert 
of  Cabot's  "^  series  treated  by  the  older  conservative  meth- 
ods.   One  cannot  maintain  from* this  that  perhaps  the  im- 
provement after  splenectomy  was  only  a  coincidental  re- 
mission, because  the  onset  of  improvement  was  too  closely 
and  constantly  related  to  the  postoperative  period ;  but  it 
does  offer  some  basis  for  the  contention  that  other  methods 
of  treatment  may  yield  results  as  striking  as  those  fol- 
lowing splenectomy.    However,  from  the  aspect  of  dura- 
tion of  the  disease  the  evidence  is  more  in  favor  of  the  sple- 
nectomized  series.  Tn  Cabot's  series,  almost  half  died  in  the 
first  year  of  the  disease,  and  of  the  remainder,  one-third  died 
in  the  next  year  (compare  Table  LXVII) .    As  the  dura- 
tion of  the  disease  in  the  splenectomized  series  had  already 


SPLENECTOMY  TREATMENT 


S21 


averaged  one  and  one-half  years  before  operation,  they 
should  be  more  properly  compared  with  the  remainder  of 
Cabot's  group.  By  tie  end  of  the  first  year  conditions 
in  the  splenectomized  group  were  as  follows:  Of  thirty- 
three  patients  surviving  the  operation,  twenty-four  were 
still  improved,  three  had  failed  to  show  improvement  or 
had  relapsed  to  their  pre-operative  condition,  and  six  had 
(lied.  If  postoperative  deaths,  however,  are  included,  only 
about  half  of  those  whose  fate  was  known  were  still  alive 
at  the  end  of  the  first  year.  From  both  these  points  of 
view,  therefore,  there  are  no  clear  indications  as  to  the  value 
of  splenectomy. 

TABLE  LXVII 
Results  Accordinq  to  Duration  op  Disease,  Based  on  Ninett-Fivb  Cases 


- 

Number 

of 

cases 

Poatoperative  reaulta 

Subse- 

DuratioQ 

Deaths 

"X:^       Improved 

quently 
Uievi 

Undor  6  months                 .... 

17 
26 
36 
16 

4 
4 
3 
6 

13 
3               19 
6              27 
1                 9 

Six  months  to  1  year 

3 

8 

Over  2  years 

4 

The  changes  in  the  blood  picture  after  splenectomy  are 
striking  and  fairly  constant.  Forty-seven  cases  are  stat^ 
to  have  had  a  distinct  postoperative  blood  crisis  (appear- 
ance of  normoblasts,  megaloblasts,  reticulated  er>i;hrocytes, 
Jolly  bodies,  etc.,  in  larger  quantities) ;  and,  as  statements 
that  the  blood  cr'  j  failed  to  appear  are  very  rare,  it  is 
fair  to  assume  that  such  a  phenomenon  is  at  least  a  fre- 
quent occurrence.  In  most  of  the  patients  who  recovered 
the  stimulation  forms  soon  grew  fewer  in  number  and, 
coincident  wtith  thd  signs  of  general  improvement,  the 
haemoglobin  and  red-cell  count  rose.    The  csolor-index,  how- 

21 


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THE  SPLEEN  AND  AN.EMIA 


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ever,  usually  remained  high.  As  might  be  expected,  also, 
the  nucleated  forms  became  fewer  or  disappear!  d ;  and  yet 
statements  are  almost  unanimous  that  the  microscopic 
features  of  the  blood  (tendency  to  macrocytosis,  poikilocy- 
tosis,  etc. ) ,  even  in  many  cases  that  showed  almost  nonnal 
counts,  remained  suggestive  of  pernicious  ana?mia.  Those 
patients  who  died  within  the  first  six  weeks  after  operation 
showed  eitlier  very  slight  improvement  in  the  blood  picture 
or  an  actual  deterioration ;  whereas,  death  occurring  after 
that  period  was  in  many  cases  preceded  by  a  distinct  im- 
provement in  the  blood  picture,  with  the  usual  signs  of  a 
remission. 

Those  few  patients  who  up  to  the  present  time  have 
continued  well  after  operation  must  also  be  taken  into  ^n- 
sideration.  By  the  older  methods  of  treatment,  Cabot,  in 
the  fir'^t  edition  of  "  Modern  Medicine,"  stated  that  six  out 
of  1200  cases  after  six  years  of  health  might  be  said  to 
have  l)een  cured.  In  the  second  edition  this  number  was 
reduced  to  three.  May  it  not  develop  that  a  larger  per- 
centage of  such  "  cures  "  will  follow  splenectomy,  even 
though  the  blood  picture  does  not  return  absolutely  to 
normal  ?  Another  point  brought  out  by  study  of  the  blood 
picture  at  the  time  of  operation  is  that  if  the  operation  is 
undertaken  before  the  blood  has  reached  an  extreme  degree 
of  deterioration,  not  only  is  the  operative  risk  lessened, 
but  the  impri  ement  is  greater  and  more  lasting.  In  any 
case  it  is  wise  to  precede  it  with  one  or  more  transfusions. 

The  average  age  of  the  patients  at  the  time  of  operation 
(see  Table  LXVIII )  was  forty-five ;  the  average  duration 
of  the  disease  at  that  time,  1.6  years.  If  the  results  are 
analyzed  in  groups  subdivided  according  to  age,  it  appears 
(as  one  would  expect)  that  less  favorable  results  are  ob- 


SPLENECTOMY  TREATMENT 


823 


tained  in  patients  in  the  sixth  and  seventh  decades.  A 
similar  arrangement  on  the  basis  of  duration  of  the  disease 
shows  tliat  the  best  results  are  obtained  (after  the  operation 
has  been  successfully  passed)  in  those  patients  who  have 

TABLE  LX\'III 

Results  According  to  Age  of  Patient,  Based  on  One  Hundred  and 

Twenty-One  Cases 


decade 

Number 
cases 

rustniierative  ruaults 

Subse- 
quently 
died 

Deaths 

Not  improved 

Improved 

:id 

8 
23 
43 

28 
9 

2 
4 
5 
4 
5 

1 

2 
2 
5 
2 

5 
17 
36 
19 

1 

4th 

2 

5th 

8 

6th 

6 

7th 

1 

had  the  disease  for  less  than  one  year.     Sex  has  not  been 
found  to  exert  any  influence  on  the  results. 

When  arranged  according  to  the  degree  of  anaemia  at 
the  time  of  operation,  one  fact  is  patent :  that  the  operative 
risk  is  much  greater  in  those  cases  in  which  hemoglobin 
is  below  20  (see  Table  LXIX).    This  is,  of  course,  for 

TABLE  LXIX 

Results  According  to  Preoperative  Degree  of  AN.«aiiA,  Based  on  On» 
Hundred  and  Fourteen  Cases 


Number 

of 

cases 

9 
29 
33 
43 

Postoperative  results 

Subse- 

HiBmaglnbin 

Deaths 

Not  im- 
proved 

Improved 

quently 
died 

Rplow  20                   

7 

6 
2 
7 

1 

2 
2 

1 

21 

29 

I5elow  30     

3 

Below  40      

7 

7        1       29 

5 

this  disease,  a  lower  level  even  than  that  of  1,000,000 
erythrocytes. 

Except  for  this  point,  on  account  of  the  great  fluctua- 
tions in  blood  counts  incident  to  the  disease  and  following 


Sii 


TIIE  SPLEEN  AND  AN.EMIA 


I  - 


transfusions,  it  is  difficult  to  estimate  whether  or  not  the 
previous  condition  of  the  blood  has  any  marked  influence 
on  the  result  obtained.  The  impression  is  gained,  however, 
that  the  best  results  follow  splenectomy  in  those  cases  that 
are  not  extremely  ana?mic  at  the  time  of  operation  and  that 
have  shown  considerable  fluctuations  in  the  bhwd  picture. 

Information  as  to  the  size  of  the  spleen  was  secured  in 
eighty-nine  cases  (see  Table  T.XX).  In  twenty-eight 
eases  (31  per  cent.)  the  spleen  was  either  small  or  approxi- 

■^ABLE  LXX 
Results  According  to  Size  of  jspleen,  Based  on  Eiqhty-.nine  Cases 


Number 

of 
casea 

Postoperative  results 

Subn- 

Siio  of  spleen 

Deaths          ^^^  »'""       Improved 
proved 

quently 
died 

Normal  or  diniinishwl 

28 
41 
20 

9        i        5 
4 

1         1         1 

14 

32 
18 

2 
9 

Considerably  enlurgcil 

3 

mately  normal  in  size.  In  forty-one  cases  (46  per  cent.) 
the  spleen  was  slightly  enlarged  (between  250  and  500 
gm.)  ;  and  in  twenty  cases  (23  per  cent.)  it  was  consider- 
ably enlarged.  In  other  words,  although  seldom  palpable 
before  operation,  it  was  distinctly  enlarged  in  over  two- 
thirds  of  the  cases.  If  the  resul's  of  splenectomy  are 
subdivided  according  to  the  size  of  the  spleen,  it  will  be 
seen  that  etter  postoperative  results  were  obtained  in 
the  cases  with  enlarged  spleens.  The  third  gn  up  in  this 
arrangement,  however,  is  the  only  one  that  could  be  said 
to  have  fared  better  than  another  as  regards  the  ultimate 
outcome  of  the  disease. 

The  EtTKCT  Produced  by  Splenectomy. — Whatever 
tlie  cause  of  the  distinct  improvement  after  splenectomy 
in  those  patients  who  sui-vivc  the  operation,  it  is  obvious 


SPLENECTOMY  TREATMENT 


325 


that  it  is  not  due  to  the  removal  of  the  sole  cause  of  the 
disease.  If  Eppinger's  theory  of  thickened  arteriole  walls 
in  the  spleen,  with  consequent  damming  back  and  destruc- 
tion of  red  cells  in  the  splenic  pulp,  were  correct,  removal 
of  the  spleen  should  indeed  cure  the  disease ;  but  our  studies 
show  that  this  is  not  the  case.  On  Eppinger's  theorj',  also, 
the  characteristic  remissions  of  pernicious  ansmia  would 
be  difficult  to  explain. 

The  postoperative  blood  crisis  discussed  above,  and  the 
subsequent  improvement  in  the  blood  picture,  decrease  in 
urobilin,  etc.,  indicate  both  that  a  stimulus  has  been  applied 
to  the  bone-marrow  and  that  a  source  of  blood  destruction 
has  been  removed.    Lee's  findings  of  an  increased  number 
of  platelets  after  splenectomy  would  also  support  the  bone- 
marrow  stimulation  theory.    Hypotheses  to  explain  these 
phenomena  have  been  unsatisfactory  and  the  relevant  ex- 
perimental evidence  often  contradictory.     Klemperer  be- 
lieves that  the  bone-marrow  activity  is  induced  by  removal 
with  the  spleen  of  an  inliibiting  hormone,  but  from  ex- 
pt  riments  in  our  laboratory  we  have  found  ^*°  (in  normal 
animals,  to  be  sure)  not  only  that  this  bone-marrow  activity 
does  not  occur  until  after  several  months  have  elapsed,  but 
also  that  fresh  splenic  extract  stimulates  ^'^'^  instead  of  in- 
hibiting the  bone-marrow.    The  cause  for  the  blood  crisis, 
therefore,  must  probably  be  sought  elsewhere :  perhaps,  as 
has  been   suggested,   in   bone-marrow  stimulation   from 
metabolic  products  or  from  abnonnal  constituents  of  the 
erythrocytes  that  are  allowed  to  remain  in  the  blood  by 
the  removal  of  the  spleen  (Decastello) .    It  is  also  difficult 
to  prove  that  the  lessened  hemolysis  after  splenectomy,  as 
sliown  by  decreased  output  of  urobilin,  is  actually  due  to 


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the  absence  of  the  spleen.  Neither  normal  spleens  nor 
those  removed  at  operation  in  cases  of  blood  disease  (Cole- 
man, Stewart,  Robertson)  can  be  shown  to  possess  demon- 
strable haemol\i;ic  activity,  and  studies  of  the  blood  enter- 
ing and  lea^^ng  the  spleen  have  also  failed  to  throw  light 
on  the  supposed  ha?molytic  function  of  this  organ  (Krumb- 
haar  and  Musser  ^^* ) . 

Another  factor  to  be  considered  is  changes  in  the  red 
blood-cells  themselves.  In  one  case  that  I  had  an  oppor- 
tunity to  study  (Stewart's),  the  resistance  of  the  erythro- 
cytes was  distinctly  increased  after  splenectomy,  so  that 
this  might  constitute  one  of  the  factors  of  improvement 
after  operation.  A  similar  increase  in  the  resistance  of 
the  erj'throcj-tcs  we  have  found  to  be  the  rule  ^"^  after  the 
removal  of  the  spleen  in  normal  animals,  and  it  is  present 
in  other  blood  diseases,  but  has  been  denied  in  some  cases 
of  pernicious  anaemia  (Moffitt). 

Whatever  the  cause  of  the  improvement,  it  is  highly 
probable  that  the  subsequent  deterioration  is  due  to  other 
related  structures  taking  over  the  functions  of  the  spleen 
(hsemolymph-nodes,  accessory  spleens,  Kupffer  cells  in  the 
liver,  and  perhaps  ordinary  l\Tnph-nodes),  although  here, 
also,  no  positive  evidence  has  as  yet  been  produced.  Assum- 
ing that  the  cause  of  the  disease  has  not  been  removed, 
the  logical  sequence  would  be  that  when  these  auxiliary 
organs  have  suiticiently  developed  the  interrupted  course 
of  the  disease  would  be  resumed. 

As  to  the  few  patients  who  up  to  the  present  time  have 
continued  well  after  operation,  if  the  curative  acti  n  of 
splenectomy  is  denied,  one  must  assume  either  that  the 
cau-sative  factor  has  for  reasons  imknown  ceased  to  op*  rate, 


SPLENECTOMY  TREATMENT 


327 


or  that  the  auxiUarj-  organs  have  failed  to  develop  into 
pernicious  activity. 

INDICATIOKS  FOR  SPLENECTOMY  IN  PERNICIOUS  An^- 

MiA. In  what  types  of  pernicious  ana?mia,  then,  should 

splenectomy  be  undertaken?     One  of  two  lines  may  be 
followed,  and  it  is  as  yet  too  early  to  say  which,  if  either, 
is  correct.    If  splenectomy  merely  induces  a  remission— 
and  this  is  at  present  the  opinion  of  the  majority  of  ob- 
servers—it should  be  logical  to  undertake  it  only  as  a  last 
lesort,  when  all  other  measures  have  proved  unavailing, 
and  only  with  the  hope  of  prolonging  life.     Even  under 
such  limitations,  however,  the  procedure  has  already  proved 
its  value,  and  in  several  cases  moribund  patients  have  been 
brought  back  to  life  cf  comparative  well-being  for  many 
months.    Assuming,  on  the  other  hand,  that  an  occasional 
patient  may  be,  for  practical  purposes,  cured  of  the  disease, 
and  giving  due  weight  to  the  view  that  greater  and  longer 
continued  improvement  is  obtained  if  the  operation  is  per- 
formed before  the  disease  has  reached  its  final  stage,  it 
would  then  be  advisable  to  undertake  it  as  soon  as  possible. 
Another  factor  that  may  prove  to  be  decisive  is  whether 
or  not  increased  haemolysis  can  be  proved.    In  those  cases 
with  clinically  enlarged  spleens,  icteroid  appearance,  and 
increased  urobilin  output,  without  increased  resistance  of 
the  er\i:hrocytes,  the  prognosis  is  distinctly  more  favorable 
than  in  the  opposite  types.    The  condition  of  the  bone- 
marrow  is  also  important,  splenectomy  being  contra-indi- 
cated if  the  bone-marrow  is  persistently  aplastic.    It  has 
also  been  a  matter  of  clinical  observation  that  those  indi- 
viduals in  whom  spinal-cord  symptoms  have  already  de- 
veloped are  less  apt  to  be  helped  by  the  operation. 


ml 


THE  SPLEEN  AND  .VN^MIA 


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Summary  of  Results  of  Splenectomy  in  Pernicious 

An^.mia 

1.  Of  the  153  patients  studied,  19.6  per  cent,  died 
within  six  weeks;  a  distinct  improvement  in  the  clinical 
condition  and  in  the  blood  picture  occurred  in  04.7  per 
cent.,  and  no  improvement  in  15.7  per  cent. 

2.  The  rather  hi^h  postoperative  mortality  (practically 
20  per  cent.)  may  be  due  to  poor  choice  of  cases  in  the 
early  series.  As  a  much  greater  proportion  of  the  more 
recent  cases  has  survived  the  operation,  the  true  postopera- 
tive mortality  is  probably  much  less  than  20  per  cent. 

3.  Of  the  individuals  who  showed  improvement  shortly 
after  operation — nearly  two-thirds  of  the  total  number — 
a  large  number  have  failed  to  maintain  this  improvement, 
or  have  since  died  in  a  relapse  or  from  intercurrent  disease. 

4.  Although  a  few  have  continued  in  good  condition 
during  the  period  of  observation  (over  two  years),  in  no 
case  can  it  be  said  that  a  cure  has  been  effected,  and  the 
blood  of  these  individuals  continues  to  show  many  of  the 
characteristic  signs  of  pernicious  anaemia. 

5.  On  account  of  the  improvement  that  follows  splenec- 
tomy, it  would  appear  to  be  not  only  a  justifiable,  but  in 
many  cases  an  advisable,  procedure ;  but  in  no  case  should 
a  cure  be  promised  or  the  operation  undertaken  except 
under  the  most  favorable  conditions. 

6.  The  best  results  are  obtained  if  the  operation  is  pre- 
ceded by  one  or  more  transfusions,  and  those  patients  who 
relapse  after  operation  may  still  be  greatly  helped  by  trans- 
fusion. Whether  or  not  transfusions  would  have  produced 
equally  good  results  in  the  absence  of  splenectomy  is  a 
question  that  cannot  at  present  be  decided. 

7.  The  most  favorable  results  may  be  expected  in  indi- 


1^ 


SPLENECTOMY  TREATMENT 

riuuals  who  have  not  passed  the  fifth  dvX^ade,  in  whom  the 
disease  has  not  progressed  for  more  than  a  year,  and  who 
have  a  relatively  good  blood  pictm-e  (that  is,  an  anaemia 
that  is  not  of  too  extreme  a  degree  or  of  the  steady,  pro- 
gressive type).  Individuals  with  enlarged  spleens  have 
done  better  than  those  in  whom  the  spleen  was  small  or  of 
normal  size,  as  have  also  those  suffering  from  an  an«mia 
characterized  by  excessive  ha?molysis. 

8.  The  opposite  of  these  conditions  should  be  considered 
as  unfavorable  factors,  as  should  also  the  existence  of 
spinal-cord  symptoms  or  the  presence  of  an  aplastic  bone- 
marrow. 

Choice  of  Time  for  Operation.— On  general  prin- 
ciples it  may  be  said  that  splenectomy  should  be  under- 
taken as  soon  as  the  diagnosis  is  definitely  settled.     In 
certain  instances,  however,  exceptions  must  be  made.    A 
"  crisis  of  deglobulization  "  in  haemolytic  jaundice  or  a 
severe  hemorrhage  from  a  mucous  membrane  in  Banti's 
disease  would  indicate  postponement  of  the  operation  until 
the  conditions  are  more  favorable.    The  existence  of  a  pos- 
sible contributing  factor,  as  indicated,  for  example,  by  the 
finding  of  a  positive  Wassermann  reaction  or  of  malarial 
organisms,  would  naturally  postpone  operation  until  the 
influence  of  such  factors  had  been,  so  far  as  possible,  elimi- 
nated.   When  the  anaemia  is  severe— and  this  applies  par- 
ticularly to  pernicious  anaemia — a  series  of  blood  trans- 
fusions (^ often  four  or  more)   should  precede  operation. 
If  the  patient's  blood  in  this  way  is  temporarily  enriched, 
not  only  is  +he  operative  risk  lessened,  but  more  lasting 
benefit  ensues.    Good  results  have  been  obtained  in  per- 
nicious ansemia  by  the  subcutaneous  or  intraperitoneal 
injection  of  splenic  extract,*''  and  in  cases  where  the  so- 


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THE  SPLEEN  AND  ANAEMIA 


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"1, 


called  "  blood  crisis  "  fails  to  materialize  after  splenectomy, 
indicating  a  failure  of  the  bone-marrow  to  respond,  this 
procedure  might  be  tried. 

It  may  be  said,  in  summarizing,  that  splenectomy  has 
already  prove<l  its  worth  in  many  clinical  conditions.  Even 
in  those  conditions  in  which  the  early  enlargement  of  the 
spleen  is  apparently  of  a  protective  nature,  evidence  exists 
to  show  that  after  a  certain  stage  its  hyperplasia  results 
in  an  increased  functioning  that  is  more  harmful  to  the 
organism  than  otherwise.  When  this  stage  is  reached,  re- 
moval of  the  spleen  usually  effects  at  least  a  temporary 
improvement  in  the  patient's  condition.  Splenectomy 
should  certainly  be  given  careful  consideration  in  all  the 
diseases  characterized  by  evidences  of  increased  blood  de- 
struction, and  the  fact  must  be  emphasized  that  in  early 
Banti's  disease  and  the  haemolytic  jaundices  the  results 
have  been  excellent  and  in  many  cases  have  practically 
amounted  to  a  cure.  Such  an  operation,  however,  should 
be  regarded  conservatively,  so  long  as  so  much  of  the  physi- 
ology of  the  spleen  remains  unknown. 


PART  III 

SURGICAL  OBSERVATIONS 
BY  CHARLES  H.  FRAZIER 


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CHAPTER  XV 

THE  SURGICAL  TREATMENT  OF  LESIONS  OF  THE 

SPLEEN 
In  the  first  century  Pliny  made  the  observation,  of 
merely  historical  interest  to  us,  that  sometimes  the  spleen 
is  a  peculiar  hindrance  to  runners,  so  that  it  is  burned  awa,y 
from  those  who  are  incommwled  by  it;  also  it  has  been  said 
that  the  Romans  removed  the  spleen  from  some  of  their 
gladiators  to  give  them  greater  endurance  in  contests.  It 
is,  however,  a  far  cry  from  that  day  to  the  i  neteenth  cen- 
tury, and  it  was  only  toward  1860,  in  the  latter  part  of  this 
century,  that  splenectomy  was  admitted  to  the  roll  of  ac- 
cepted and  approved  surgical  procedures,  while  the  most 
important  contributions  to  the  surgery  of  the  spleen  have 
been  offered  during  the  past  five  years. 

The  lesions  for  the  treatment  of  which  the  surgeon 
is  called  upon  to  operate  are  varied  and  numerous.  Be- 
ginning with  injuries,  such  as  wounds  and  rupture,  there 
were  added  wandering  spleen,  malarial  spleen,  abscess  of 
the  spleen,  Banti's  disease,  the  tAvo  types  of  haemolytic 
icterus,  and,  finally,  pernicious  anaemia. 

Gtimhot  and  Stab  Wounds.— The  spleen  enjoys  a 
measure  of  protection  from  its  position  beneath  the  left 
costal  arch,  but  occasionally  it  is  injured  by  bullet  and  stab 
wounds.  As  with  all  injuries  to  the  spleen,  hemorrhage 
is  at  once  profuse  and  alarming  and,  unless  surgical  relief 
is  immef^ately  available,  the  patient  dies  of  shock  or  col- 
lapse. Should  the  splenic  arterj'  itself  or  the  vein  be  punc- 
tured with  or  without  penetration  of  the  spleen,  hemor- 

333 


!i 


334 


THE  SPLEEN  ASB  .SJV^MIA 


i 


'  I 


phage  will  be  no  profuse  that  the  life  is  lost  before  surgical 
treatment  can  be  applied.  The  diagnosis  can  be  only 
conjectural,  but  suspicion  should  be  aroused  by  the  con- 
:ititutional  signs  of  profuse  hemorrhage,  with  perhaps  dul- 

TABLE  LXXI 
Results  or  the  Tbe.-tment  of  52  Cases  of  Stab  Wodnd  bv  Vabiocs  Methods 


i^ptsratiun 

Total 
csacs 

14 
24 
12 

2 

52 

Recovered 

Died 

9 
22 
10 

1 

5 

2 
2 

1 

Suture 

Treatment  not  siiecified 

Totals      

42 

10 

19.49 

percent. 

TABLE  LXXII 
Rmultb  of  the  Treatment  of  82  Cases  of  Gunghot  Wound  bt  Vabioub 


Methods 


Operation 


Splenectomy 

Tamponage 

Suture 

Partial  excision 

Ciiuteriz;ition 

Trratment  not  specified 

Diuth  previous  to  opera- 
tion   

Wounds  not  detected  at 
the  operation 

Totals   


Total 
caaea 

ReooTere'i 

Died 

40 

25 

15 

18 

10 

8 

9 

5 

4 

1 

1 

— 

1 

— 

1 

6 

1 

5 

1 

— 

1 

6 

— 

6 

82 

42 

40 

48.2 

per  cent. 

ness  on  percussion  in  the  left  flank  or  when  the  site  or  direc- 
tion of  the  wound  points  to  the  spleen.  Immediate  opera- 
tion is  imperative,  and  the  treatment  of  the  injured  organ 
will  depend  somewhat  upon  the  extent  and  character  of 
the  wound.  Bullet  and  stab  wounds  may  be  efTectively 
dealt  with  by  suture,  but  when  there  is  more  or  less  ex- 


SURGICAL  TREATMENT  OF  LESIONS 


3S5 


tensive  laceration,  when  hemorrhage  cannot  be  otherwise 
controlled,  or  wlK>n  the  vessels  of  the  pedicle  are  involved, 
splenertomy  is  clearly  indicated.  In  superficial  wounds 
the  insertion  of  a  free  epiploon  has  been  used  advantage- 
ously for  the  control  of  hemorrhage.  Of  ninety-nine  cases 
of  wounds  of  the  spleen,  50  per  cent,  of  the  s'xty-one  cases 
of  gunshot  wounds  and  80  per  cent,  of  the  thirty-e\ght 
stab  wounds  t^'v   vered  (Finkelstein  ""). 

Rupture  of  the  Spleen. — Rupture  may  be  designated 
as  traumatic  or  spontaneous — the  former  the  result  of 
trauma  upon  a  healthy  organ,  the  latter  implying  an  organ 
already  the  seat  of  a  pathologic  lesion,  often  of  an  inflam- 
matory nature,  be  it  malarial,  typhoidal,  or  tuberculous. 
Rupture  of  the  spleen  follows  accidents  not  unlike  those 
which  would  cause  a  rupture  of  the  kidney,  but  in  the  ma- 
jority of  instances  the  kidney  will  rupture  and  the  spleen 
escape.  The  passage  over  the  body  of  wagon  wheels, 
crushes  beneath  heavy  objects,  automobile  and  railroad 
accidents,  the  kick  of  horse  or  man,  falling  upon  angular 
objects,  or  falls  from  a  distance  may  be  numbered  among 
the  possible  causer.,  and  together  with  the  ruptured  sple-.-', 
one  often  finds  fracture  of  one  or  more  ribs. 

As  with  gunshot  or  stab  wounds,  rupture  of  the  spleen 
can  he  surmised  only  by  the  character  of  the  injury,  by  the 
evidence  of  an  overwhelming  hemorrhage  with  signs  of 
profound  shock  or  collapse,  by  the  presence  of  dulness  in 
the  flank,  accompanied  in  the  occasional  case  by  fracture 
of  the  ribs  in  the  left  side.  While  there  are  instances  of 
spontaneous  recovery,  the  majority  of  cases  of  rupture  of 
the  spleen  would  be  rapidly  fatal  without  surgical  inter- 
ference. Imnip  1  i  f  te  operation  should  be  the  rule  whenever 
rupture  J  tV-  .een  is  suspected,  and  the  measure  to  be 
adopted  will  depend  upon  the  extent  and  depth  of  the 


'A 


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ru 


.i:l 


'ill 


336 


THE  SPLEEN  AND  ANEMIA 


i^' 


(.■: 


,   i 


••n»' 


wound.  If  the  latter  be  superficial,  hamostasis  may  be 
effected  by  simple  suture  or,  as  Kirschner*'*  suggested, 
by  the  envelopment  of  the  organ  with  fascia.  At  all  events, 
one  should  give  preference  to  conservative  practice,  if  not 
thereby  adding  to  the  risk  of  operation.  There  may  be 
many  instances,  particularly  after  massive  hemorrhages, 
when  the  more  radical  operation,  splenectomy,  may  be  done 
more  expeditiously  than  one  or  the  other  of  the  conserva- 
tive methods  and  should  therefore  be  the  method  of  choice. 

Mortality  of  Rupture  of  the  Spleen 
table  lxxiii 

I.   MiCHELSSON 


Operation 

Cases 

Hecovered 

Died 

Splenectomy 

254 
24 
10 
10 

166 

19 

8 

6 

88 
5 
2 

4 

'^r;iiTii;M)ii!iirp           

Total" 

298 

199 

09 

33.2 

per  cent. 

TABLE  LXXIV 

n.    LlTERATUUE    OF   THE    La8T    FiVE   YeARS 


Upeiatiun 

Cases 

Hecovered 

55 

8 
4 

Died 
13 

6H 

11 

4 

Suture    

Totals 

83 

67 

16 

19.3 

JKT  rent. 

Of  208  cases  in  Michelsson's  -""  collection,  treated  in 
various  ways  (Table  LXXIII ) ,  the  mortality  was  33.2  per 
cent.,  while,  excluding  all  but  those  operated  upon  from 
1910  to  1915,  the  mortality  has  fallen  to  19.8  per  cent.,  or 
almost  one-half  (Table  LXXIV.) 


SURGICAL  TREATMENT  OF  LESIONS 


337 


The  prognosis  of  spontaneous  rupture  of  the  spleen  is 
influenced  by  the  nature  of  the  patholooric  process.  If, 
prior  to  the  rupture,  the  patient's  condition  have  been  de- 
preciated by  a  more  or  less  virulent  and  prolonged  infec- 
tion, as  of  malaria  or  typhoid  fever,  the  likelihood  of  siu-- 
vival  after  an  m-erwhelming  hemorrhage  is  naturally  less 
than  when  rupture  occurs  in  an  other^vise  healthy  subject 


or  organ. 


Abscess. — Because  of  its  vascularity  and  the  slowness 
of  its  blood  current  tlie  spleen  is  frequently  the  site  of  infec- 
tion, either  by  the  microorganisms  themselves  or  by  infec- 
tious emboli.  Thus  we  have  the  secondarj-^  infection  of  the 
spleen  in  the  acute  fevers,  such  as  typhoid  and  typhus,  or  in 
septicjemia,  and  the  primary  involvement  of  malaria,  tuber- 
culosis, syphilis,  and  cchinococcus  disease.  An  abscess  of  the 
spleen  may  develop  secondarily  to  any  focus  of  infection 
and  occasionally  may  result  from  a  contiguous  infection, 
as  from  perforation  of  the  stomach  or  subphrenic  abscess. 
Because  of  the  greater  frecjuency  of  malaria,  dysenterj', 
and  typhoid  fever,  in  tropical  countries,  and  of  the  peculiar 
susceptibility  of  the  spleen  to  these  infections,  abscess  of 
the  spleen  is  of  greater  incidence  in  the  warm  and  tropical 
climati  ,  than  in  the  temperate  zone. 

The  diagnosis  of  splenic  abscess  is  frequently  not  made 
until  the  infection  has  extended  beyond  the  capsular  limits. 
A  palpable  spleen  or  one  enlarged  and  tender  may  be  of 
little  significance  and  the  symptoms  may  vary  according 
to  whether  the  abscess  be  located  in  the  upper  or  lower  pole. 
If  in  the  lower  pole,  an  enlarged  and  painful  swelling  may 
be  felt;  if  in  the  upper  pole,  the  most  suggestive  signs  are 
those  of  diaphragmatic  invasion  or  diaphragmatic  pleurisy. 
^\Tiile  there  may  be  theoretical  objections  to  explorntory 

22 


] 


!,t:l,,r 


fWh 


I;!; 


338  THE  SPLEEN  AND  ANAEMIA 

aspiration,  it  seems  to  have  been  practiced  frequently  with- 
out untoward  effects  an<l  must  be  reco^iized  as  the  most 
rehable  of  all  the  diagnostic  guides.  The  diagnosis  once 
established,  recourse  should  be  had  to  surgical  intervention, 
since  spontaneous  rupture  of  the  abscess  usually  terminates 

fatally. 

The  surgical  treatment  of  abscess  of  the  spleen  may 
imply  either  a  splenotomy  or  a  splenectomy.     While  the 
choice  of  operation  must  be  left  to  the  judgment  of  the 
operator,  generally  speaking  the  safer  operation  of  the  two 
is  splenotomy,  and  this  is  especially  the  case  if  the  spleen 
be  surrounded  with  adhesions.    Splenectomy  should  be  re- 
served for  those  exceptional  cases  where  the  spleen  is  free 
from  adhesions  and  can  be  removed  without  the  dangers 
of  contamination  of  the  peritoneum.    The  approach  to  the 
abscess  ii  splenotomy  may  be  transpleural,  abdominal,  or 
retroperitoneal.      The   tr.nnspleural    route    is    peculiarly 
adapted  to  upper-pole  involvement,  especially  when  the 
pole  is  surrounded  by  adhesions  or  the  infection  has  ex- 
temled  to  the  subdiaphragmatic  space  or  the  pleural  cavity. 
The  problem  thus  becomes  similar  to  that  of  dealing  with  a 
left-sided  sub-  or  epi-diaphragmatic  abscess.  If  the  visceral 
or  parietal  pleura  be  not  adherent,  the  operation  is  divided 
into  two  stages,  being  content  at  the  first  with  suture  of  the 
parietal  pleura  to  the  diaphragm.    Otherwise,  after  resec- 
tion of  a  portion  of  the  rinth,  tenth,  or  eleventh  rib  in  the 
post-axillary  line,  the  operator  proceeds  at  once  to  open  the 
abscess  through  the  diaphragm. 

To  expose  and  drain  an  abscess  in  its  lower  pole  or, 
if  need  be.  to  remove  the  spleen,  ready  access  is  obtained 
by  the  abdominal  route.  The  incision  runs  parallel  with 
the  last  rib.  and  the  latter  should  be  resected,  if  necessary 


SURGICAL  TREATMENT  OF  LESIONS 


889 


to  establish  direct  drainage.  During  the  exploratory  steps 
and  during  evacuation  of  the  abscess  the  peritoneal  cavity 
must  be  protected  from  soiling.  The  retro- peritoneal 
route  to  the  spleen  seems  at  once  the  least  appropriate 
and  the  most  complicated.  As  described  by  Propping, 
who  speaks  favorably  of  it,  the  exposure  is  made  through 
an  incision  from  the  tip  of  the  twelfth  rib  along  the  lower 
margin  of  the  eleventh  rib.  If  need  be,  the  twelfth  and 
part  of  the  eleventh  rib  may  be  resected.  With  the  finger 
as  a  guide,  the  spleen  or  the  abscess  may  be  reached  by 
follov.ing  from  below  upward  the  surface  of  the 
diaphragm. 

The  immediate  operative  mortality  of  abscess  of  the 
spleen  varies  from  about  10  to  25  per  cent.,  being  lowest 
for  typhoidal  abscesses,  where  the  infection  at  the  time  of 
the  operation  is  often  attenuated.  The  ultimate  prognosis 
n:ust  be  presented  in  a  less  favorable  light  when  the  splenic 
abscess  is  but  on-  of  a  number  of  pathological  lesions  or  is 
merely  an  intercurrent  infection  in  the  course  of  a  pro- 
longed or  essentially  chronic  infection.  The  early  recog- 
nition of  the  lesion  and  its  proper  management  would  be 
attended  with  a  relatively  low  mortality  were  it  not  for 
these  extraneous  and  coincident  complications. 

The  Malarial  Spleen.— The  removal  of  the  spleen  from 
malarial  subjects  is  not  necessarily  a  curative  procedure, 
and  the  course  of  the  disease,  even  to  a  fatal  issue,  may  be 
uninfluenced.  On  the  other  hand,  it  is  also  true  that  in 
many  cases  removal  of  the  spleen  is  followed  by  a  general 
amelioration  of  the  patient's  condition  and  even  by  recov- 
er}'. The  indications  for  splenectomy  in  malarial  subjects 
are  threefold :  a  chronic  malarial  fever,  a  wandering  spleen, 
and  a  weighty  spleen,  but,  as  the  mortality  is  high,  the 


'V: 


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840  THE  SPLEEN  AND  AN.iiMLV 

operation  should  be  reserved  for  those  cases  in  which  in- 
vahdisni  is  pronounced  and  where  there  are  no  serious 
changes  in  liver  or  kidneys.    Not  only  does  improvement 
follow  because  of  the  elimination  of  an  infective  focus,  but 
the  removal  of  a  weighty  organ  relieves  the  patient  of  dis- 
comfort, restores  to  normal  the  relation  of  the  abdominal 
organs,  and  removes  the  hindrance  to  their  circulation. 
"Whether  splenectomy  should  be  encouraged  in  the  later 
stages  of  malaria  with  ascites,  a  clinical  state  not  unhke 
the  third  stage  of  Banti's  disease,  is  open  to  question. 
Finkelstein,' '"  who  has  had  an  unusual  experience  in  a 
malarial  chniate,  considers  v  operation  advisable  when 
the  hanioglobin  is  not  less  than  thirty  or  forty  per  cent., 
when  the  red  blood-corpuscles  are  not  less  than  2,000,000, 
when  there  is  no  (x-dcma  of  the  lower  limbs,  when  there  is 
no  parenchymatous  lesion  of  the  '  .idneys,  when  the  patient 
is  able  to  move  about.    Unfortunately,  there  are  no  means 
of  determining  serious  degeneration  of  the  liver,  since  the 
presence  of  a  serious  hepatic  or  renal  lesion  spells  disaster 
after  an  operation.    In  the  sur\'iving  patients  the  ascites 
disappears,  and  in  two  of  Finkelstein's  cases  the  fluid  did 
not  reaccumulate  and  the  condition  of  the  patient  left  noth- 
ing to  be  desired.     The  operative  problems  in  malaria 
are  virtually  those  of  any  disease  in  which  there  may  be  a 
perisplenitis  and  consequent  adhesions. 

Tuberculous  Spleen.— Tuhercnlosis  of  the  spleen  is 
secondarv  to  a  primary'  lesion  elsewhere.  Up  to  1909, 
Fischer  "«  had  been  abl  ?  to  collect  but  twelve  cases,  and 
since  that  time  there  have  been  but  few  additions.  The 
operation  has  usually  been  performetl  because  of  an  en- 
larged and  wandering  spleen  and  the  presence  of  tuber- 
culosis, suspected  and  not  discovered  until  examination  of 
the  sjx   imen  upon  its  removal. 


SURGICAL  TREATMENT  OF  LESIONS 


341 


Syphilis  of  the  Spleen.— SiAenectomy  has  been  per- 
formed for  both  the  fruiainatous  and  non-guinmatous  sple- 
nomegaUes.  Giffin  '*'  speaks  of  the  advantageous  removal 
of  the  spleen  in  the  non-gmnmatous  splenomegaly  asso- 
ciated with  syphilis.  The  spleen  has  been  found  to  contain 
spirochete,  and  after  its  removal  there  has  been  a  rapid 
diminution  in  the  size  of  a  previously  enlarged  liver.  Fur- 
thermore, whereas  before  the  operation  the  Wassermann 
reaction  continued  positive  despite  appropriate  treatment, 
after  removal  the  reactions  were  returned  as  negative. 
This  relationship  of  the  spleen  to  the  continuation  of  syphi- 
lis, the  spleen  sen-ing  as  a  favorable  medium  for  the  propa- 
gation of  the  organism,  is  a  recent  observation  and  is  preg- 
nant with  possibilities. 

Wandering  Spleen.— The  spleen,  for  various  causes, 
may  make  wider  excursions  in  the  abdominal  cavity  than 
any  other  organ.  It  has  been  found  in  the  sac  of  an  ingui- 
nal hernia  and  often  in  the  pelvis,  where  it  has  been  mis- 
taken for  uterine  or  ovarian  tumor.  It  may  change  its 
position,  as  the  patient  moves  from  side  to  side,  when  it 
usually  gravitates  to  the  lowest  point;  it  may,  however, 
float  upwards  on  the  intestines;  it  may  become  fixed  by 
dhesion  in  an  abnormal  position,  a  condition  to  which  is 
applied  the  term  "  dislocated  spleen." 

In  most  instances  the  causes  of  wandering  spleen  are 
acquired,  although,  in  exceptional  instances,  congeni- 
tal elongation  of  the  mesentery  may  permit  of  a  wide 
excursion.  The  more  common  causes  are  accessions  in 
weight,  elongation  of  the  pedicle  and  ligaments,  and  re- 
laxation of  the  abdominal  walls  often  associated  with  vis- 
ceroptosis (Glenard's  disease).  Consequent  upon  this 
wider  range  of  motion,  which  as  a  matter  of  fact  occurs 


ami  I 


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342 


THE  SPLEEN  AND  ANAEMIA 


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most  often  in  the  malarial  spleen,  certain  complications 
may  develop,  chief  among  wliich  are  engorgement  and 
twists  of  the  pedicle.  The  former  is  a  gradual  process  and 
may  add  considerably  to  the  weight  of  the  spleen,  to 
the  weight  of  which,  under  normal  circumstances,  the  blood 
contributes  forty  per  cent.  Twists  or  rotation  of  the  pedi- 
cle will,  of  course,  aggravate  the  engorgement  and  may 
in  turn  lead  to  hemorrhages,  gangrene,  and  even  peritonitis. 
The  rotation  may  vary  from  180  dtgrees  to  360  degrees, 
and  upon  the  suddenness  and  degree  of  rotation  will  de- 
pend the  development  of  an  acute  or  chronic  symptom- 
complex.  Sudden  rotation  of  the  splenic  pedicle  may  de- 
termine an  abdominal  catastrophe,  mistaken  often  for  in- 
testinal obstruction  or  peritonitis,  marked  by  tenderness, 
abdominal  rigidity,  vomiting,  distention,  and  by  the  pres- 
ence of  an  enlarged,  tender,  and  palpable  swelling.  In 
chronic  cases  there  is  not  only  the  splenic  enlargement,  but, 
by  virtue  of  its  weight  and  displacement,  the  spleen  may 
disturb  the  function  of  other  abdominal  organs.  Epi- 
gastric distress,  nausea  and  vomiting  may  result  from 
dragging  upon  the  stomach,  and  a  train  of  symptoms  from 
pressure  upon  the  uterus  and  its  adnexa.  Not  only  may 
the  stomach  be  dragged  out  of  position,  but  the  tail  of  the 
pancreas  may  be  elongated,  and  the  uterus  displaced  or 
even  prolapsed. 

Theoretically,  the  ideal  treatment  of  wandering  spleen 
is  splenopexy.  This,  however,  presumes  the  presence  of  a 
nonr  al  organ,  a  condition  rarely  found.  Since  in  the  vast 
majority  of  cases  wandering  of  the  spleen  is  primarily  due 
to  splenomegaly  of  one  variety  or  another,  often  a  malarial 
spleen,  splenectomy  is  the  most  satisfactory  and  most  logi- 
cal treatment. 


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SURGICAL  TREATMENT  OF  LESIONS 


343 


Tumors  and  Cysts.— The  spleen  may  be  the  seat  of 
primary  or  secondary  growths:  of  the  primar>'  growths 
the  adenoma,  fibroma,  and  lymphoma  have  been  found,  but 
not  on  the  operating  table.  The  secondary  malignant  tu- 
mors of  the  spleen  are  not  of  practical  moment,  but  a 
limited  number  of  primary  sarcomata  have  been  disclosed 
at  exploratory  operations  and  removed.  They  take  their 
origin  from  the  capsule  or  trabecula,  the  lymphoid  struc- 
ture, and  the  endothelial  cells.  One  may  suspect  the  pres- 
ence of  a  sarcoma  of  the  spleen  should  there  be  an  enlarged 
and  tender  organ,  of  nodular  surface  and  firm  consistency, 
with  palpable  notches  and  a  rapid  increase  in  size.  Provid- 
ing metastases  are  not  already  detected,  the  organ  should 
be  removed. 

Cysts  of  the  spleen  may  be  large  or  small,  of  parasitic 
or  non-parasitic  origin.  The  parasitic  or  hydatid  cyst  is 
quite  the  most  coaimon,  and  its  contents  display  the  fea- 
tures characteristic  of  hydatid  cysts  elsewhere.  It  is  inter- 
esting to  note,  hoAvcver,  that  they  usually  originate  in  the 
upper  part  of  the  organ,  and,  as  they  increase  in  size,  they 
may  interfere,  by  pressure  upward  upon  the  diaphragm, 
with  the  action  of  both  lungs  and  heart.  When  feasible, 
splenectomy  is  the  operation  of  choice,  but  when  the  re- 
moval of  the  organ  seems  prohibitive  from  the  standpoint 
of  safety,  the  operator  must  be  content  with  incision  and 

drainage. 

Non-parasitic  cysts  of  the  spleen  include  the  dermoid, 
serous,  blood  and  lymph  cysts.  The  first  mentioned  is  so 
rare  as  not  to  be  of  practical  moment,  while  the  others  are 
often  so  small  as  to  pass  unrecognized.  The  blood  cyst 
owes  its  origin  to  hemorrhage,  either  parenchymatous  or 
subcapsular,  and  is  often  the  result  of  an  injury.    A  history 


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344 


THE  SPLEEN  AND  ANAEMIA 


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of  trauma  followed  by  the  sudden  appearance  of  a  splenic- 
enlargement  is  a  significant  diagnostic  feature.  Other 
diagnostic  signs  include  a  tumor  of  the  left  hypochondriimi 
of  a  cystic  nature,  pain  and  tenderness,  embarrassment  of 
respiration  if  the  cyst  be  of  large  dimensions,  and,  more 
specifically,  a  creaking  sensation  communicated  to  the  ex- 
amining hand,  as  with  respiration  the  roughened  surface 
of  the  cyst  and  the  abdominal  wall  come  in  contact. 

Splenomegali/. — Of  the  pathological  conditions  of  the 
spleen  in  the  treatment  of  which  splenectomy  is  an  accepted 
method  of  procedure  there  remain  to  be  considered  the 
splenomegalies  with  ana?mia.  The  classification  adapted 
in  this  monograph  recognizes  the  following  types: 

1.  Gaucher's  disease  (large-celled  splenomegaly). 

2.  Banti's  disease. 

3.  von  Jaksch's  disease  (pseudoleukfemia  infantum). 

4.  Chauff ard-Minkowski  or  congenital  form  of  hitmo- 
lytic  jaundice. 

5.  Hayem-Widal  or  acquired  form  of  ha?molji;ic 
jaundice. 

6.  Pernicious  anosmia. 

These  several  types  of  splenomegaly  have  been  treated 
in  eoctenso  in  earlier  chapters;  suffice  it,  at  this  juncture, 
to  speak  briefly  of  their  surgical  aspects.  As  a  general 
fundamental  principle,  the  best  results  may  be  expected 
from  splenectomy  in  those  diseases  in  which  there  is  evi- 
dence of  increased  blood  destruction.  In  this  category  would 
fall  hfrmolytic  jaundice  and  some  cases  of  pernicious  ansv- 
mia.  Good  results  have  also  been  obtained  in  Banti's  dis- 
ease and  in  the  few  cases  of  Gaucher's  and  von  Jaksch's 
disease  that  have  been  saidicd.  but  in  accepting  these  as 
positive  indications  for  splenectomy  the  proviso  must  be 


SURGICAL  TREATMENT  OF  LESIONS 


345 


made  that  promising  results  can  be  expected  in  Banti's 
disease  only  when  the  operation  is  performed  in  the  early 
stage.  The  secondary  changes  which  take  place  in  the  liver 
of  the  patient  with  Banti's  disease  are  not  materially  influ- 
enced by  the  removal  of  the  spleen,  and  when  the  liver  is 
obviously  enlarged  the  propriety  of  the  operation  should  be 
seriously  questioned. 

In  the  list  of  doubtful  indications  for  splenectomy  I 
place  pernicious  ansmia.    The  surgery  of  pernicious  anne- 
mia  at  this  wTiting  is  suh  judice.    As  yet  there  have  been 
no  recoveries  following  splenectomy,  although  there  have 
been  many  instances  of  prolongation  of  life,  general  better- 
ment of  the  patient's  condition,  and  in  lengthening  of  the 
periods  of  remission.    The  operation,  therefore,  is  not  with- 
out influence  upon  the  course  of  the  disease  and  may  be 
practiced  in  selected  cases,  with  the  knowledge,  on  the  part 
of  the  patient,  that  the  operation  is  in  the  nature  of  a  pal- 
liative procedure  and  not  in  any  sense  cvu-ative.    Further- 
more, it  must  be  borne  in  mind  that  in  some  cases  repeated 
transfusions  may  be  almost  as  eff"ective  as  splenectomy, 
and  that  even  when  the  latter  is  practiced  transfusions  may 
be  required. 

The  Removal  of  the  Spleen 
Anatomical  Considerations.— The  splenic  artery,  itself 
a  branch  of  the  coeliac  axis,  divides  into  seven  or  more 
branches  which  supply  the  spleen,  the  pancreas,  and  the 
stomach.  To  the  latter  is  given  off  the  vasa  brevia,  passing 
l)etween  the  layers  of  the  gastrosplenic  omentum  to  be  dis- 
tributed to  the  great  cul-de-sac,  and  the  left  gastro-cpiploic, 
coursing  between  the  layers  of  the  great  omentum  to  the 
greater  curvabire.  In  the  operation  of  splenectomy  the 
splenic  artery  is  exposed  for  ligation  in  the  pedicle,  but 


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346  THE  SPLEEN  AND  AN.EML\ 

when  ligation  of  the  arter>'  is  to  be  substituted  for  splenec- 
tomy, tlie  artery  may  be  exposed,  according  to  Gerster, 
through  an  opening  in  the  lesser  omentum  just  above  the 
lesser  cur%'ature  of  the  stomach.    The  first  two  inches  of 
the  artery  lie  just  beneath  the  posterior  parietal  peri- 
toneum, and  may  be  brought  nearer  the  level  of  the  anterior 
abdominal  incision  by  placing  an  Edebohl  cushion  beneath 
the  patient's  back.     The  splenic  vein,  or  splenic  veins— 
for  there  are  often  more  than  one  in  the  pedicle — unite  with 
the  superior  mesenteric  to  form  the  portal  vein,  so  that  a 
thrombus  of  the  '  'tter  seriously  interferes  with  the  splenic 
circulation.    The  pedicle  of  the  spleen  varies  in  length.  The 
shorter  the  pedicle  the  more  difficult  are  all  the  stages  of 
splenectomy,  including  the  delivery  of  the  organ  and  the 
ligation  of  its  vessels.    It  is  comprised  of  connective  tissue 
and  fat,  occasionally  of  lymphatic  nodes,  some  accessory 
spleens,  and  the  tail  of  the  pancreas  ( Plate  X ) ,  and  through 
the  pedicle  pass  the  splenic  artery,  and  one  or  more  veins. 
The  smaller  vessels  to  the  stomach  lie  anterior  to  the  ped- 
icle.    In  addition  to  the  splenic  artery  and  veins  which 
enter  the  spleen  at  the  hilum.  there  is  a  leash  of  vessels 
which  enter  the  spleen  through  what  Richards  calls  a  sec- 
ondary hilum  near  the  lower  pole.    These  vessels  are  car- 
ried in  a  fold  of  peritoneum  that  is  reflected  on  the  surface 
of  the  splenic  flexure  of  the  colon. 

The  capsule  of  the  spleen  is  so  firmly  adherent  to  the 
surface  that  attempts  at  separation  would  be  Jittended 
with  laceration  of  the  pulp;  therefore  a  subcapsular  sple- 
nectomy is  not  feasible. 

A  knowledge  of  the  relationship  of  the  spleen  to  the 
contiguous  structures  is  of  practical  moment.  The  supe- 
rior pole  is  in  dose  relation  with  the  diaphragm  and  the 


I'l.All.   .\ 


The  ri'lutiuiislnp  ■■(  the  tiul  fi  Ilu   imrn  ii;i.-.  tu  llie  l..p^tl'lIur  a»iifi-l  "t  Ihf  pttlicle 


ri  Ai  i:  M 


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llii-  piTitciiiiil  ]ir..liii]f:ili.iii  l..l\»i'iri   111!'   .splicii   Mini    llii'   h|.liliH'   lliMiri'    i^f    tlif   i-oliili,    wliicli 
unj!.!   Ill'  iliMiliil  lirliirc  I  111'  iiiKiiii  I  nil  111    i"iii|il<  1<  l.\    niubilueil. 


SURGICAL  TREATMENT  OF  LESIONS 


347 


lower  pole  through  a  peritoneal  reflexion  with  the  splenic 
flexures  of  the  colon.  In  the  pancreatic  notch  behind  the 
hilum  lies  the  tail  of  the  pancreas,  and  its  relation  to  the 
structures  of  the  pedicle  has  already  been  mentioned.  This 
is  a  matter  of  practical  consideration,  since,  unless  care  be 
taken  to  avoid  it,  a  portion  of  the  tail  may  be  amputated 
in  division  of  the  pedicle  after  ligation.  This  accident  has 
occurred  more  than  once.  So  close  does  the  greater  curva- 
ture of  the  stomach  lie  to  the  pedicle  of  the  spleen  that  a 
portion  of  the  wall  has  been  inadvertently  excised,  in  one 
instance  with  a  fatal  result. 

The  spleen  is  maintained  in  its  position  under  normal 
conditions  by  a  number  of  Ugaments,  by  the  gastrosplemc 
ligament,  the  lienorenal,  by  an  occasional  band  to  the  lower 
pole  derived  from  the  phrenocolic  ligament  (Plate  XI), 
and  by  its  pedicle.    Under  abnormal  conditions— and  it  is 
mostly  under  these  that  splenectomy  must  be  performed— 
the  ligaments  above  mentioned  are  fortified  by  adhesions 
of  such  density  and  vascularity  that  they  may  make  the 
operation,  if  not  impossible,  at  least  surrounded  with  many 
difficulties.     The  most  troublesome  adhesions  are  those 
from  the  outer  surface  and  upper  pole  to  the  diaphragm, 
but  there  may  be  others  to  the  stomach,  large  bowel,  and 
parietal  peritoneum.    W.  J.  Mayo  calls  attention  to  the 
vascular  connections  in  the  deeper  portions  of  the  gas- 
trosplenic  omentum,  which  pass  inward  and  backward  to 
anastomose  with  vessels  along  the  spine  and  crux  of  the 
diaphragm.    These  vascular  connections  must  be  divided 
before  the  spleen  can  be  delivered. 

Blood  Tramfusion.—B\ood  transfusion  frequently  may 
be  called  for,  either  in  the  preparation  for  operation  or 
in  the  after-treatment  of  the  splenectomized  patient.  Fol- 


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348 


THE  SPLEEN  AND  AN/EMLV 


lowing  the  alarming  hemorrhages  of  wounds  and  rupture 
of  the  spleen,  the  transfusion  of  blood,  if  in  the  emergency 
a  suitable  donor  can  be  found,  may  be  a  life-saving  remedy. 
In  such  situations  the  transfusion  is  performed  immediately 
after  the  operation.  When  splenectomy  is  contemplated  in 
the  chronic  case,  be  it  Banti's  disease,  ha?molytic  icterus, 
splenic  anaemia,  or  pernicious  ana-mia,  transfusion  plays  a 
verj'  important  role  in  the  preparation  of  the  patient  for 
operation.  Should  the  ha'moglobin  be  below  thirty  or 
forty  per  cent.,  the  patient  should  be  transfused  forty- 
eight  hours  before  the  time  set  for  the  splenectomy  and 
again  after  the  operation,  should  the  latter  be  attended  with 
much  loss  of  blood.  It  is,  however,  not  only  with  reference 
to  the  blood  picture  that  inquiry  be  made  into  the  patient's 
condition.  A  careful,  systematic  examination  of  the  car- 
diovascular and  renal  systems  should  be  made  to  determine 
whether,  irrespective  of  the  anaemia,  the  patient  be  a  good 
operative  risk.  It  may  well  be  in  certain  cases  that  a 
patient  with  2,000,000  red  blood-corpuscles  may  be  a  better 
hazard  than  one  with  3,000,000  corpuscles,  but  with  other 
handicaps. 

It  is  in  pernicious  anaemia,  ho  vever,  that  transfusion 
plays  the  most  important  role,  not  only  in  the  preparation 
of  the  patient  for  the  operation — the  phase  of  the  subject 
with  which  we  are  most  concerned — but  also  in  preventing 
relapses  and  prolonging  the  peri(Kl  of  remission.  Paren- 
thetically it  may  be  said  that  if  no  improvement  follow 
transfusion  little  should  be  expected  to  follow  a  splenec- 
tomy. The  effects  of  one  may  be  said  to  forecast  the  effects 
of  the  other.  Percy,  whose  large  experience  compels  a  hear- 
ing, has  evolved  a  systematic  method  of  managing  the 
transfusion  problem  to  which  I  attribute,  in  part  at  least, 


SURGICAL  TREATMENT  OF  LESIONS 


349 


his  low  mortality.     He  has  adopted  what  he  styles  the 
step-ladder  method  of  preparing  his  patients  by  transfu- 
sion ;  he  prefers  whole  blood  to  defibrinated  blood  or  blood 
treated  with  sodium  citrate;  the  average  nuinl)er  of  trans- 
fusions for  each  patient  varies  from  three  to  five,  the  aver- 
age amount  of  blood  is  640  c.c,  and  the  average  intei-val 
between  the  time  of  the  first  transfusion  and  the  splenec- 
tomy is  twenty  days.    In  almost  every  case  improvement 
follows  immediately  after  the  first  transfusion,  and  con- 
tinues by  "  step-ladder  "  progression  with  successive  trans- 
fusions until  the  patient  is  in  a  state  prepared  for  opera- 
tion.   At  the  conclusion  of  the  operation,  and  while  still 
on  the  table,  the  patient  is  transfused  again.    According 
to  Minot,  the  most  auspicious  time  for  the  splenectomy  is 
from  four  to  ten  days  after  the  transfusion,  when  the 
Howell-JoUy  bodies  appear  in  greatest  number,  together 
with  a  rise  in  the  leucocyte  count  and  an  increase  in  the 
blood-platelets  and  reticulated  cells. 

The  effect  of  transfusion  upon  the  subject  of  pernicious 
ansmia  varies  somewhat  with  the  stage  of  the  disease.  In 
the  early  cases  transfusion  may  give  a  remission  of  several 
months  and  seem  almost  as  beneficial  and  enduring  in  its 
effects  as  splenectomy.  In  the  late  cases  the  effect  is  only 
transitory,  a  matter,  perhaps,  of  two  or  three  weeks.  But, 
while  the  transitory  effect  is  fully  recognized,  transfusion 
should  not  be  discarded,  since  it  is  in  itself  a  humane  meas- 
ure, giving  to  the  patient  a  sense  of  bon  faisance,  increas- 
ing the  appetite  and  general  l>odily  comfort,  and  unques- 
tionably prolonging  life. 

The  obligation  of  the  surgeon  in  the  selection  of  a  suit- 
able donor  need  only  be  mentioned.  That  vigilance  is 
required  to  protect  the  patient  from  transmissible  diseases 


u 


:3i 


S60  THE  SPLEEN  AND  ANAEMIA 

may  be  inferred  from  the  transmission  of  syphilis  in  one 
reported  case  where  the  donor,  denying  exposure  to  infec- 
tion, had  the  primary  lesion  at  the  time  of  the  transfusion. 
In  the  selection  of  a  donor  the  matter  of  blood  compatibility 
must  be  investigated  with  great  care  in  order  to  preclude 
even  the  remotest  possibility  of  hemolysis  or  agglutination. 
Technic  of  Splenectomtj.—The  removal  of  the  spleen 
under  certain  conditions  is  an  operation  devoid  of  any 
peculiar  difficulties.    When  the  spleen  is  not  enlarged,  or 
when  the  adhesions  are  few  and  so  readily  divided  that  de- 
livery of  the  organ  is  a  simple  manoeuvre,  splenectomy 
might  be  compared  with  an  uncomplicated  nephrectomy. 
The  problems  are  somewhat  similar:  the  manner  of  ap- 
proach (that  is,  the  incision),  the  isolation  of  the  organ 
and  its  delivery,  the  management  of  the  pedicle,  and  the 
after-care  of  the  wound.    But  the  difficulties  of  the  difficult 
splenectomy  quite  exceed  the  difficulties  of  the  difficult 
nephrectomy,  and  the  chief  point  of  difference  between  the 
two  lies  in  "the  presence  of  dense  vascular  adhesions  with 
which  the  spleen  may  be  surrounded.    For  the  preferable 
line  of  incision  one  must  choose  a  midline  incision,  be- 
tween an  incision  at  the  junction  of  the  middle  or  outer 
third  of  the  rectus  and  an  incision  in  the  linea  semiluna- 
ris.    Each  of  these  incisions  may  have  its  advantages 
under  certain  conditions,  or  perhaps  no  one  should  be 
used  to  the  exclusion  of  others.     Personally,   I   prefer 
a  left-sided   Bevan   incision,   in   the   outer   rather   than 
the  inner  half  of  the  rectus  (Plate  XII),  as  advocated  by 
Balfour.''     The  upper  limb  of  this  incision  is  projected 
across  the  rectus  an  inch  below  the  costal  margin,  and  the 
flap  thus  formed,  when  grasped  with  a  pair  of  forceps, 
may  serve  as  a  retractor. 


m       ! 


I'l   \il     Ml 


■il 


I 


~i»| 


I.cft-Miiied  H«-vati  im-isidii  fur  ..plcnectniny. 


<2 


!.»J 


SURGICAL  TREATaIENT  OF  LESIONS  351 

Owen  Richards '•'  and  iVly  Bey,  whose  experience  has 
been  chiefly  with  large  and  adherent  spleens  of  tlie  Egypt- 
ian splenomegaly,   prefer  a   vertical   incision,    stretching 
half-way  between  the  costal  angle,  the  lower  margin  of  the 
thorax,  about  two  or  three  inches  from  the  median  line,  and 
extending  downward  a  distance  of  six  or  eight  inches.    If 
the  incision  be  in  the  midline,  access  to  the  outer  surface 
of  the  spleen  is  not  adequate,  and  if  more  external  than 
the  incision  above  described,  the  costal  margin  prevents  the 
prolongation  of  the  incision  high  enough  to  give  access  to 
the  vault  of  the  diaphragm.    With  this  left  rectus  incision 
Richards  has  but  once  had  to  add  a  transverse  cut  in  the 
rectus  to  give  additional  room  for  manipulation. 

Percy ''"'  has  quite  recently  adopted  a  midline  incision 
and  claims  for  it  advantages  over  those  nearer  the  outer 
margin  of  the  rectus.    No  doubt  he  has  been  influenced 
in  his  selection  of  a  midline  incision  by  his  practice  of 
thoroughly  exploring  the  abdomen,  particularly  the  region 
of  the  appendix  and  gall-blatlder,  in  search  for  an  in- 
fective focus  as  having  some  bearing  upon  the  pathogenesis 
of  pernicious  anaemia.    However  this  may  be,  he  has  found 
an  associated  lesion  of  the  gall-bladder  or  appendix  in 
many  of  his  cases.    In  a  series  of  twenty-four  splenectomies 
he  had  performed  twenty-one  combined  operations,  seven- 
teen splenectomies,  appendectomies,  and  cholecystectomies; 
three  splenectomies  and  appendectomies,  and  one  splenec- 
tomy with  the  removal  of  carious  teeth. 

After  exploring  the  abdomen  with  particular  attention 
to  the  condition  of  the  gall-bladder,  biliary  passages,  and 
the  liver  itself,  the  operator  proceeds  systematically  to 
prepare  the  spleen  for  delivery,  directing  his  atttention  first 
to  freeing  its  upper  pole  and  outer  surface.     To  accom- 


V 


M 


•  •  i 


352 


THE  SPLEEN  AND  ANiEAHA 


i,,  * 

i 

"i' 


plish  this,  the  right  hand  is  inserted  in  the  Lf  t  subdiaphrag- 
matic space  and  by  blunt  dissection  with  the  fingers  the 
adhesions  are  separated  as  close  to  the  spleen  as  possible 
(Plate  XIII).  This  step  of  the  operation  is  perhaps  the 
most  difficult,  because  the  field  is  not  within  view  and  hemor- 
rhage may  be  profuse.  It  may  be  necessarj-,  should  the 
adliesions  be  dense,  to  double-clamp  and  divide  them  with 
scissors.  At  this  stage  hemorrhage  may  be  temporari'y  con- 
trolled by  the  use  of  a  hot  pack  (Plate  XIV),  postponing 
until  later  ligation  of  those  points  still  bleeding  after  the 
spleen  has  been  removed.  The  hot  pack,  a  feature  of  AV.  J. 
JVIayo's  technique,  serves  a  two-fold  purpose:  permanently 
contn)lling  a  number  of  the  bleeding  points,  especially 
those  of  venous  origin,  and,  secondly,  serving  as  a  support 
for  the  subsequent  manipulation  and  mobilization  of  the 
spleen.  After  the  adhesions  to  the  upoer  and  outer  sm*- 
faces  are  free  and  the  space  tamponed,  the  lower  pole  is 
drawn  up  and  the  lienorenal  ligament  with  its  vessels 
divided  between  two  ligatures.  Before  the  pedicle  can  be 
satisfactorily  dealt  with  there  remains  to  be  divided  the 
gastrosplenic  omentum,  between  the  layers  of  which  pass 
the  vasa  brevia  on  their  way  to  the  stomach.  Ihe  close 
relationship  of  the  stomach  to  the  spleen  must  be  borne  in 
mind  at  this  juncture,  since  in  the  division  and  ligation  of 
the  gastrosplenic  ligament  the  stomach  may  be  inadvert- 
ently opened.  Freed  from  all  attachments  save  the  pedicle, 
the  spleen  is  now  mobilized  cautiously  until  the  pedicle  is 
exposed.  To  accomplish  this  an  assistant  supports  the 
lower  pole,  and  the  operator,  with  his  right  hand  upon  the 
upper  pole  and  his  left  depressing  the  outer  margin  of 
the  abdominal  incision,  by  gentle  traction  and  pressure 
mandouvres  the  spleen  through  the  abdominal  wound.    The 


i'l.Aii;  xiii 


:i 


Kir.-,!  ^Iii,  in  tin.   irml.iii/Mt,..n   .if   thr   ^plr.i,      W.th    ill.'   ritrhl    Iniii.I   Hi- .r  .'il  ..r  MlKiriiliB  IliP 

ii.lh.-si.ins  1"  tw.Tii  thr  .■.ii|MTi..r  Miif:i.'i-  ..(  llii-  .splci'ii  mti.I  the  .liniilinigni. 


I'l  All;  XIV 


\ 


■'" ""■"'   l'l''''ll">.'   .ift.r   nH,l,ili^;,ti,i„   ,  ,f  i1m>   ,,,]■.■„    ;,    l:,,l,-   l:ll, ,,,,,„    ,,f  t.„,l,r.    „,„I,C  ,.lH    in    lint 

Will.  I.  L-  nil  r... hi.  1.1  11,1.1  I  III    Irf  I  In  I lii.iiiliHiiii 


I'l  All;  \v 


Tr:\oti"iiiiniiEati<>ii  iiftiT  is.'I:i1ion    -.f   tlip   vr^^vU   nf   tlir    ,  r.VuAv   V.y  bhmt    n'tnuvi.l    <'f   f;it   nil. 


i 


%M\ 


ml 


ii' 


L 

9 


I'l  Ml.    N\  I 


; » 


•  «  t* 

"1' 


Tlii>  .Iiiul>li'-cliiii.|i  iiiilli.i.;     f  .li':i)iin!  with  till-  iieilii'Io. 


SURGICAL  TRFATMENT  OF  LESIONS 


353 


difficulty  in  delivery  has  been  said  to  be  in  direct  pro- 
portion to  the  lirnuiess  of  the  adhesions  and  sometimes  in 
inverse  proportion  to  the  size  of  the  spleen.  When  the 
spleen  is  large  and  weighty  sufficient  support  must  be  ap- 
plied to  prevent  undue  traction  and  laceration  of  the  struc- 
tures of  the  pedicle. 

The  most  important,  though  not  always  the  most  diffi- 
cult, step  of  splenectomy  is  the  treatment  of  the  pedicle. 
Grave  hemorrhage  may  attend  the  proce^  ^  of  ligation 
should  the  ligature  slip  and  the  vessel  retract,  or,  after  the 
patient  has  been  returned  to  bed,  should  an  insecure  liga- 
ture become  dislodged.     As  a  general  principle,  it  is  a 
safer  plan  to  ligate  the  pedicle  in  sections  as  the  vessels  pre- 
sent themselves  (Plate  XV),  although  when  the  pedicle 
is  short  it  may  be  necessary  to  apply  clamps  and  ligate 
en  masse.    By  blunt  dissection  of  the  peritoneal  covering 
and  connective  tissue  each  vessel  is  isolated  for  an  inch  or 
more  and  di\  ided  between  two  ligatures,  the  distal  ligature 
being  tied  close  to  the  spleen.    The  ligatures  should  be  tied 
as  far  apart  as  possible  and  the  vessel  divided  near  the 
spleen  so  as  to  leave  a  long  stump  centralward.  There  are 
usually  two  or  more  veins  to  be  dealt  with  and  one  or  more 
arteries,  according  to  whether  t!^.e  artery  divide  before  it 
enters  the  hilum.    Theoretically  the  art  ry  should  be  tied 
first  in  order  that  the  spleen  may  at  least  partially  empty 
itself  of  its  blood  content. 

Fractional  ligation  of  the  pedicle  must  be  discarded 
for  ligation  en  masse  when  the  pedicle  is  too  short.  Very 
much  as  in  nephrectomies,  the  clamp  is  used  when  the 
pedicle  is  so  short  that  the  vessels  cannot  be  easily  exposed. 
Two  curved  rubber-covered  forceps  are  applied  to  the  ped- 
icle (Plate  XVI),  three-quarters  of  an  inch  apart,  and  the 
23 


I'.i' 


li.! 


iliir 


f 


\.  ' 


iltv 


m 


S54 


THE  SPLEKN  AND  ANiEMIA 


i.:> 


\-J-.  ■ 

,    ) 

''|b. 

c) 

HiSEl^B'' 

A- 

|&j^S|^Bt 

"H 

I^^^^^H;. 

i-i' 

■■-'"^Bf 

l.4i 

'.^_^i^:^'t .  :^^P  Ji 

1-' 

fl^ 

Jl 

spleen  cut  away  without  regard  to  back  bleeding  (Mayo), 
but  after  the  splenic  artery  has  been  tied  or  clamped  bleed- 
ing from  the  spleen  itself  is  no  great  loss  to  the  patient, 
although,  as  graphically  described  by  Richards,  this  back 
bleeding  is  "  mussy  and  demoralizing."    A  catgut  ligature 
is  thrown  about  the  pedicle  as  the  proximal  clamp  is 
loosened  and  the  ligature  tied  in  the  compressed  area.  The 
distal  pair  of  forceps  is  used  to  steady  the  pedicle  while 
the  proximal  ligature  is  tied,  and  for  further  security  a 
second  ligature  is  employed.     In  the  application  of  the 
clamps  by  this  methotl  the  operator  is  again  cautioned  not 
to  include  the  wall  of  the  stomach  or  the  tail  of  the  pan- 
creas.   After  the  pedicle  has  been  ligated  and  the  spleen 
removed  the  proximal  stump  should  be  given  a  final  in- 
spection to  make  sure  of  the  security  of  the  ligature.    If 
there  still  remain  oozing  points,  these  should  be  taken  care 
of,  and  should  the  stump  of  the  pedicle  be  broad  it  may 
be  overrun  with  a  fine,  continuous  catgut  suture  or  covered 
with  omentum. 

Gerster  believes  that  ligation  of  the  arterial  supply 
at  points  more  accessible  than  the  deeply-situated  splenic 
pedicle  will  greatly  facilitate  matters  in  difficult  opera- 
ations.  These  points  are  the  splenic  artery  close  to  the 
coeliac  axis  and  the  left  gastro-epiploic.  where  it  reaches 
the  stomach  wall.  The  coeliac  axis  is  exposed  and  the  sple- 
nic arter\'  ligated  through  an  opening  in  the  lesser  omen- 
tum ;  the  left  gastro-epiploic  is  ligated  just  before  it  begins 
to  send  off  branches  to  the  arteries  and  posterior  surfaces. 
With  the  arterial  stre  ..ns  under  control,  Gerster  feels  a 
greater  sense  of  security  in  dealing  with  the  vessels  of  the 
pedicle  should  difficulty  be  encountered  or  accidents  hap- 
pen.   After  the  vessels  of  the  pedicle  have  been  dealt  with, 


SURGICAL  TREATMENT  OF  LESIOxNS 


855 


the  preliminary'  ligatures  of  the  splenic  and  left  gastro- 
epiploic artery,  if  only  temporary,  may  be  released,  so 
that  if  any  arterial  branches  in  the  pedicle  have  been  over- 
looked they  may  now  be  tied.  There  is  no  serious  objec- 
tion, according  to  Cierster,  to  allowing  the  ligatures  to  re- 
main. While  the  pancreatic  and  vasa  brevia  branches  of 
the  splenic  artery  are  shut  off  from  their  direct  arterial 
source,  the  pancreas  and  stomach  wall  still  have  an  abun- 
dant arterial  su^^ply  through  other  branches  and  anasto- 
mosing relationships.  This  suggestion  of  temporary  dis- 
tant ligation  of  the  vessels  may  prove  of  sen^ice  in  excep- 
tional cases,  but  so  far  as  I  know  it  has  not  as  yet  been 
put  into  actual  practice. 

The  pedicle  divided  and  the  spleen  removed,  the  hot 
pack  is  slowly  withdrawn  and  an  inspection  made  for 
points  of  hemorrhage  from  divided  adhesions.  These  are 
best  controlled  with  mounted  ligatures.  With  htemostasis 
satisfactorily  established,  the  operation  is  concluded  by 
closure  of  the  splenic  space.  This  Mayo  regards  as  ex- 
ceedingly important  and  introduces  what  he  terms  a 
snaking  suture,  as  follows: 

"  With  catgut  on  a  small  curved  needle,  the  raw  space 
begimiing  at  the  tied  splenic  vessels  is  close<l  as  well  as 
possible.  The  margin  of  the  lienorenal  ligament,  on  the 
outer  side,  is  sufficiently  firm  to  hold  a  suture,  but  on  the 
inner  side  such  bits  of  tissue  must  be  caught  here  and  there 
as  can  be  done  safely  until  the  bleeding  vessels  are  com- 
pressed. The  last  s\itures  come  well  down  in  the  dia- 
phragm and  had  best  be  applied  during  cardiac  diastole 
and  during  expiration." 

The  purposes  of  the  operation  fulfilled  and  the  field 
dry,  the  wound  is  closed  without  drainage,  although  to 


r'l     ki- 


::.)., 


;  J 


l..»J 


g^g  THE  SPLEEN  AND  AN^MU 

this  treneral  rule  exceptions  may  be  taken-on  the  one 
ha^^dYf  the' wound  be  L  entirely  dry,  or  if  the  field  may 
hrve  been  soiled  !»'  an  accidental  injury  to  stomach  or 

"^^"^For  many  reasons  the  most  serious  complication  of 
splenectomy  is  henmrrhage.     The  fragility  of  the  splen.c 
veins  exposes  them  to  laceration  when  too  much  traction  is 
pu"  upcm  the  pedicle;   in  the  case  of  an  atheromatous 
LleniJ  artery  a  ligature  may  tear  through;  should  a  hga- 
tZ  clamp  slip  7rom  the  pedicle  the  stump  of  the  d.vu  ^ 
vessel  quick  V  retracts  beneath  the  costal  margm;  in  the 
eTaratlm  of  adhesions  the  capsule  may  be  torn  and  the 
p  enic  pulp  bleed  freely;  the  adhesions  themselves  may 
be  ex  remelv  vascular  and  cor  tain  a  well-developed  arterj' 
uH  number  of  varicose  veins;  ligation  of  the  va^  brevia 
or  the  gastrosplenic  omentum  may  be  troublesome      fhe 
spleen  itself  has  been  described  as  an  elastic  bag  full  of 
Wood  under  pressure,  and  the  splenic  vessels,  when  cut, 
b  eed  furiously  from  either  end.    Its  blood  content  equal 
for  V  per  cent,  of  its  weight,  and  this  in  enlargea  spleens 
mav  amount  to  more  than  a  quart.    It  matters  Mtle,  how- 
^v^-,  whether  the  artery  or  vein  be  first  hgated :  he  amount 
of  blcK>d  it  contains  after  removal  is  practically  the  same  m 

^'*  WhilTthe  sources  of  hemorrhage  are  many,  the  im- 
pression must  not  be  gained  that  a  splenectomy  is  usually 
Attended  with  the  loss  of  a  considerable  quantity  of  blood, 
n  h  atence  of  adhesions  I  have  completed  the  open^^on 
with  the  loss  of  not  more  than  two  teaspoonfuls  of  blood 
Tnd  though  the  potential  sources  of  hemorrhage  are 
numerous  with  careful  attention  to  methods  of  preven- 
S^n  Tnd  to  methods  of  control,  even  in  difficult  cases,  the 


SURGKWL  TREATMENT  OF  LESIONS 


357 
have  had 


'III 


loss  of  blood  may  be  within  reasonable  limits, 
no  experience  witli  the  preoperative  administration  of 
adrenalin,  which  is  said  to  cause  marked  shrinkage  of  the 
organs,  but  have  been  content  with  the  effect  of  normal 
saline  solution,  intravenously  or  with  blood  transfusion, 
when  the  amount  of  blood  lost  at  the  operation  might  retanl 
the  patient's  convalescence.  In  cases  of  pernicious  ana'mia 
Percy  ^**  routinely  transfuses  the  patient  while  still  on  the 
operating  table. 

As  complications  of  splenectomy,  apart  from  hemor- 
rhage, should  be  mentioned  injuries  to  adjacent  viscera. 
Mention  has  been  made  of  the  proximity  of  the  stomach 
and  of  its  occasional  injury  dm-ing  splenectomies  and  of 
the  intimate  relationship  of  the  tail  of  the  pancreas  to  the 
pedicle  and  hilum.  Even  when  a  portion  of  the  tiil  of  the 
pancreas  has  been  included  in  the  ligature  of  the  pedicle, 
no  seriou.  '•onsequences,  such  as  fat  necrosis  from  the  pan- 
creatic secretion,  have  been  reported. 

The  operative  sequelae  of  splenectomy  are  varied.  With 
the  exception  of  shock  and  collapse,  as  in  cases  of  grave 
hemorrhage,  the  most  frequent  complication  is  bronchitis 
or  pneumonia.  The  susceptibility  of  the  splenectomized 
patient  to  infection  is  a  factor  to  be  reckoned  with,  but  this 
alone  does  not  explain  why  the  lung  should  be  the  site  of 
election  for  the  coincident  infection.  Nor  can  the  relative 
frequency  of  pneumonia  be  attributed  to  a  transitory  para- 
lysis of  the  diaphragm,  because  these  pneumonias  develop 
on  the  right  side  as  well  as  the  left.  Whatever  may  be  the 
cause,  the  fact  remains  that  pneumonia  is  a  common  of m- 
plication ;  and  in  one  of  my  cases,  a  splenectomy  for  Banti's 
disease,  the  patient  developed  after  the  pneumonia  a  pneu- 
mococcic  peritonitis,   from  both  of  which,  however,  she 


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jjg  THE  SPLEEN  AND  AN.EML\ 

m.de  an  excellent  recovery.    Of  the  causes  of  death  other 
^:iXe  aUributable  to  the  an.nna,  I  n.ay  -n.on^oc 
nain  hemorrhage,  pneumonia,  suppression  of  unne,  niesen 
S' thrombosis,  portal  thrombosis,  and  acute  ddatat.on  of 

^''TCoperative  risks  of  splenectomy  must  of  necessity 

the  mortality.    As  our  knowledge  of  the   "'«  =" 
operation  has  developed  as  ou.  J^^JJ^™  ™  .ta^Xsion 

atoJ'jaX  series  of /iaWstei...'  who^eo^  *  h^^ 
mortality  for  66  cases  ro,n  «0^^  »/»J»;;^  J  ».th  a 
Carstens  collected  a  screes  ol  J  spleneelomies 

mortality  of  27.4  per  cent.  In  »  '"''■^  "'J  ^^  ^^,^  jeath- 
i„  malarial  suhjeets,  ^-^  -f,fXfl;  operation 

^^'^WnThas'lUntdnld  "trially  may  he  inferred 
can  be  and  has  oeen  icuu  ^^.^^^^p*;  with  pernicious 

from  the  reports  of  more  recent  «P  r"^«J*/a  to  8  per 
anemia  when  the  -nortahl^rat^haVen  educ  ^^  ^  P  ^ 

cent.    This  has  heen  made  poss.me  ny  -^i^ious 

standin,  of  the  prohlems  of  *e  o^-^^™;^  ^^t  Jhe  selec- 
emplo^-ment  of  transfusion,  and  greater 

tion  of  cases. 


BIBLIOGRAPHY 


il: 


^r 


Nil' 


.  I 


BIBLIOGRAPHY 

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Achahd. 


C,  Foix,  C,  and  Salin, 


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J  ah 


iren. 


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mals.    Bk.  III.  . 
^^Vrmstrono,  G.  E.:  Splenectomy   and  Banti's  Disease.      Bnt. 

Med.  Jour.,  1906,  ii,  1273. 
"AscHENHEiM,    E. :     Ucbcr    familiarcn    hamolytischen    Ikterus. 

Munch,  med.  Woch.,  1910,  Ivii,  1282. 
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^  361 


::i 


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I! 


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1^ 

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362  THE  SPLEEN  AND  AN/EMIA 

'*AsHF.R,  L. :  Die  Funktion  der  Milz.    Deutsch.  med.  Woch.,  1911, 

xxxvii,  1-252. 
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Drusen.     XIX  Mitteilung.     Fortge>otzte  Beitriige  zur  Lehre 
von  der  Funktion  der  Milz  als  Organ  des  Eiweisstoffswechsels. 
Uber    die    Konipcnsationsvorgiingc    nach    Milzexslirpation. 
Biochem.  Zeitschr.,  1913,  Iv,  13. 
>«  AsHER,  L.,  and  Vogel,  H.  :  Beitriige  zur  Physiologic  der  Drusen. 
XVIII  Mitteilung.     Fortgesteztc  Beitriige  zur  Funktion  der 
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1912,  xliii,  386. 
'"Asher,  L.,  and  Zimmermakn,  R.:   Beitriige  zur  Physiologic  dor 
Drusen.     XII  Mitteilung.     Fortgesteztc  Beitnigc  zur  Funk- 
tion der  Milz  als  Organ  des  EisenstofTwcchsels.      Biochem. 
Zeitschr.,  1909,  xvii,  297. 
^"Assolant:  Rccherches  sur  la  Rate.     Paris,  1801.     (Not  avail- 
able.) 
=^  Austin,  J.  H.,  and  Ringer,  A.  I. :  The  Influence  of  Phlorizin  on 

a  Splcnectomi^cd  Dog.  Jour.  Biol.  Chem.,  1913,  xiv,  139. 
"Austin,  J.  H.,  and  Pearce,  R.  M.  :  The  Relation  of  the  Spleen 
to  Blood  Destruction  and  Regeneration  and  to  Ha-molytic 
Jaundice.  XL  The  Influence  of  the  Spleen  on  Iron  Metab- 
olism. Jour.  Exper.  Med.,  191 1,  xx,  122. 
"Austin,  J.  IL,  and  Pepper,  O.  IL  Pehry:  Tlie  Relation  of  the 
Spleen  to  Blood  Destruction  and  Regeneration  and  to  Haemo- 
lytic  Jaundice.  XII.  The  Importance  in  the  Production  of 
Ha-molytic  Jaundice  of  the  Path  of  Ha-moglobin  to  the  Liver. 
Jour.  Exper.  Med.  1915,  xxii,  675. 


BIBLIOGRAPHY 


363 


"AzzrRiNi,  F.,  and  Massart.  G.  :  La  morfologia  del  sangue  negli 
animali  smilzati.     Arch,  di  Biol.,  1903,  Ivii,  802;  ibid,  1904, 


25 


Vol.  I, 


Iviii,  629. 

Baii.lon  :    Opera  Omnia  Med.— Epidem.  et  Ephemer. 

Bk.  II,  p.  183  (de  Tournes,  Geneva,  1762). 

-"Baldwin,  J.  F.:  Splenectomy  for  Pernicious  Anaemia,  Apparent 

Recovery,  Death.     Med.  Rec,  New  York,  1915,  Ixxxvii,  230. 

"Balfoik,  D.  J.:   The  Technic  of  Splenectomy.     Surg.,  Gyn., 

andObs.,  1916,  vol.  23,  1. 
-'  Banti,  G.  :  La  Milza  nelle  Itterizie  P'ieiocromiche.     Gaz.  degli 

Osp.,189.5,  xvi,  489 
="  Banti,    G.  :     La    Splenomogalie    hemolytique.      Semaine    med., 
1912,   xxxii,   265.      Splenomegalie   hemolytique   anhemopoie- 
tique,  le  role  de  la  rate  dans  I'hemolysc.    Semaine  med.,  1913 ; 
xxxiii,    313.       Splenomcgalia    emolitica    anemopoieta.        Lo 
Sperimentale,  1913,  Ixvii,  suppl.,  323 
=°  Banti,  G.  :  La  Splenomegalia  con  cirrosi  epatica.      Lo  Speri- 
mentale, 1894,  Sez.  Biol.,  xlviii,  407. 
"Banti,  G.  :  La  Splenomegalia  emolitica,  patalogica,  1911,  iii, 
471 ;  La  Splenomegalia  emolitica  anemopoietica,  Uffi/io  della 
Milzo  nell  emolise.    Sperimentale,  1913,  Ixvii,  323. 
•'^  Banti,  G.  :  La  Splenomcgalia  emolitica.     Sperimentale,  1912, 
Ixvi,  91.     La  Splenomegalia  emolitica,  anemopoietica.    Speri- 
mentale, 1913,  Ixvii,  323. 
'•'Banti,  G.:  The  Clinical  Aspects  of  Ha-molysis.     Tr.  Intern. 

Cong.  Med.,  1913,  Sec.  vi.  Med.,  p.  1. 
■'*  Bardeleben  :  Note  sur  des  extirpations  de  la  rate  et  du  corps 
thyroide.     Comp.  Rend,  de  I'Acad.  de  Sciences,  Paris,  1844, 
xviii,  485. 
^■'  Bari.inc;,  G.  :  Splenectomy  for  Enlarged  Spleens  with  Ana-mia. 

Lancet,  1915,  i,  220. 
'"Barr,  J.:  Three  Cases  of  Banti's  Disease.     Lancet,  1902,  ii, 

493. 
''Bauer,  Joki,,  M.  :  Neuere  Arbeiten  ueber  die  Physiologic  und 
Pathologic  der  Milz.  Med.  Klin.,  191M.  ix,  1338. 


Iii 

rlfi 


'ill!} 


<..;:■ 


,) 


4 


J84  THE  SPLEEN  AND  ANEMIA 

'''Bayer  F  Statistiches  uber  Splenektomie  unci  Mitteilung  eine 
FallL  von  Milzexstirpation  wegen  idiopathischer  Hyper- 
trophic.    Munch.mc-d.\Voch.,190+,li,n6. 

-Bavkk,  R.:  Untersuchungen  uber  den  Eiscnstoffwochsel  nach 
dcr  Splenektomie.     Mittheil.  aus  d.  Grenz..  d.  Med.  u.  Clur 
1909,  xxi,  335 ;  ibid.,  Weitere  Untersuchungen  iiber  d.e  Funk- 
tionen  der  MHz,  vornehmlich  ihre  Role  im  E.senstotfwechsel. 
mit  besondere  Berucksichtigung  des   Morbus  Banti.      1J14, 

-B,^imz.'!u'.:  Su  di  un  caso  dl  morbo  di  Banti  curato  colla 
splenectomia.     Riv.  Yen.  d  sci.  med.,  1915,  y.xx>..  97 

^'Benech,  E.,  and  Sabhaze«,  J.:  Ictere  hen^olyf  .ue  chron.que, 
avec  splenomegalie:  Gaz.  hebd.  sci.  mod.  d-      ordeaux,  1909, 

XXX,  469.  „•  , 

-'Benedict,    S.    R.:  The    Estimation    of    Lrea.     Jour.    B.ol. 

Chcm.,  1910-11,  viii.  405.  ,        •    ,  •. 

T^  A    e,,-v-i     F  •  Feber    eine    chronisclie    nut 

"Benjamin,   E.,    and   Su  ka,    t.. .   i  tocr 

Icterus  einhergehen<les  Erkrankung  des  Blutes.      Berl.  khn. 

Woch.,  1907,  xliv,  1065.  .     ,     f 

"Bessei.-Hac.ex,  F.:  Ein  Be.trag  zur  Milzch.rurgie.     Arch.  f. 

klin.  Chir.,  1900,  Ixii,  188. 
"Bksski,-Hagen,  F.:  Verhandl.  d.  deutsch.  Gesellsch.   f.   Chir., 

1900,  xxix,  (2)  7U.  j     ,•       •      i; 

«BiAO.    N  •  Sul  nmtamento  di  poten  di  res.stenza  degh  an.mah 

luzaH.      Sperimentale,  Arch,  de  Bio..,  1907,  Ixi   295 
^»B.EaH.No,  W.  L.,  and  Ec.uahu  E.:    A  Study  of  the  Blood    n 

Bant.'s  Disease  Before  and  After  Splenectomy.     Jour.  Am. 

Med.  Ass'n.,  1906,  xlvii,  1U9. 
«'BiFF.s,  P.:   Suir  Ittero  EmoUtico.     Riform.  Med.,  191.>,  xxxi, 

"Blake     J     B.:  Banti's    Symptom-complex    with    Relation    to 

Splenectomy.      Ann.  Surg.,  1915,  Ix.i,  315. 
«B.ANn-SnTTON,  S:k   J.:  Observations  on   the  Surgery  of  the 

Spleen.     Brit,  Jour.  Surg.,  1913-U,  i,  157. 


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365 


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"Blechfr:  Subtkutane  traumatische  Milzzerreissung  bei  Mor- 
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"BoxDi,    S.:  Morbus    Banti    mit    Splenektomie.       Wien.    khn. 

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see 


THE  SPLEEN  AND  ANAEMIA 


I': 


■■l' 


"V 


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't^^nJa  im  Kindesalter.      H.ss.  di  elin.  t..a^  e^^.   ^ 

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Ga..  d.  Ospedali,  1897,  XV  -.,-.• 
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'>^"1"  7  ,„         ,.,„„    V  •   Ictere  Congenital  hemoly- 

"PHMFFAun,  A.,  and  tiKssiNc.tR.  i>--   icteii,«.w.  ^ 
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tique  avec  Lesions  (.lobulaii  ts. 

Hon  de  Paris,  1907,  xxiv,  1169. 
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S«7 


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S68 


TIIE  SPLEEN  AND  ANEMIA 


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lii  I 


?1 


^il 


SM 


THE  SPLEEN  AND  .\N.EML\ 


U 


;,) 


.1 


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i) 

.1 


,3 
J 

z 


INDEX 


li 


Abscess  of  splctn,  337 
diagnosis,   .'i.17 
opcrativ   uiort.ility,   339 
surgical  l-crtt.iu-nt  of,  337 
spltricctoiny,   .SS8 
splinotomy,   338 
Accessory  spleens  in  dog,  ^1 
Alcoholic   icterus,   255 
Agglutinins    in    blood-serum,    280 
Ammonia   nitrogen    in   congenital 
hemolytic  jaundice,  before  and 
after  splenectomy,  215 
Anaemia   in   dogs   a    factor   in   in- 
creased    hapmolytic    resist- 
ance, 50 
afte-  ligation  of  splenic  vein, 

195 
after  splenectomy,   12 

artificially  produced,   100 
methods,  100 
results    of    experiments, 

101 
repair  of.    100 
summary      of      observa- 
tions, 110 
cause    of    disturbances    of 

metabolism,  201 
causal  factor  unknown.  111 
diet,   influence   of,   22,   SO, 
34 
raw  and  cooked,  31 
experimental      conclusions, 

S3 
general    summary    of    ex- 
perimental studies,   195 
hwmorrhagic,  107 

blood  repair  after,  107 
26 


Anaemia    in    dogs,    after    splenec- 
tomy,   iron     output    in- 
creased, 119 
jaundice,  influence  of,  72 
onset  of,  1 2 
relation      to     Iwne-marrow 

changes,  158 
secondary,  1 2 

caused      by       haemolytic 

agents,   199 
sodium  oleate  type,  105 
resistance  of  red  cells  in, 
110 
spleen,  absence  of.  a  factor 
in    chronicity    .-ind    slow 
repair,  105 
spleen    feeding,    influence 
of,  97,  198 
caused  by  haemolytic  agents. 
135 
duration  of,  137 
toluylenediamine        test, 
136 
iron  metabolism  in,  199 
"  splenic,"  38 

extract,   injections   of,    in, 

other    splenettomized     animals, 

22 
in      man,     after      splenectomy, 
duration  of,  37 
metabolism,  studies  of,  in, 

228 
nitrogen  balance,  231 
pernicious    (see   pernicious 
anaemia),  265 
icteric  form  of,  26l 
"splenic,"  241,  242 

401 


INDEX 


U 


'0 


i) 


1 


Ansmia  in  man,  splenomegaly  ac- 
companied by,  iitl 
Antemia  infantum  pseudoleukffmia, 

Antihafmolytic    })roperty    of    nor- 

nnl  (lojj  serum,   l? 
Auto-af(glutinins    in    blood-scrum, 

test  for,  280 
Autolysins,  280 

Bacillus  coll.   subcutaneous  injec- 
tions     of,      producing     spleno- 
megaly, 250 
Banti's  disease,  21'8,  254 
a  syndrome,  251 
blood  changes,  252 
etiology,  249 

infectious  agent,  249 
trauma  of  spleen,  251 
pathogeneins,   249 
pathology,  253 
protein    destruction   excessive 

in,  290 
pseudo-    252 
simulated  by  syphilis  of  liver, 

252 
spleen,  causative  relationship 
of   253 
enlarjT'  III.  nt  of,  nature  of, 
25  V 
splenectomy  in,  344 

results  of,  330 
symptomatology,  248 
intermediate  stage,  249 
pre-ascitic  period,  248 
third  or  ascitic  stage,  249 
treatment  of  splenectomy,  309 
combined     with     Talma 
operation,  311 
mortality,  310 


Hile,test  for,  after  splenectomy,  54 
clianpis    in,    after   splenectomy, 
68 
formation    from   hsmoglobin, 
part  played  by  spleen  in,  59 
in    urine    of    splenectomizcd 
animals,  76 
in  absence  of  spleen,  197 

in  splenectomizcd  animals,  58 
Bilirubri     in     duodenal     contents, 
(lUiintitative     estimate,     Schnei- 
der's method,  288 
Blood,    regeneration    of,   time   of, 
after    destruction    by    hemo- 
lytic serum,  102 
repair     of,     in    splenectomized 
dog,    after    hsemor- 
rhages,  107 
sodium    oleate     anaemia, 
107 
of  spleen,  arterial  and  venous, 
comparison  of,  87 
differential  counts,  91 
reticulated  or  skeined 

red  corpnsclefl,  93 
total  hemoglobin,  91 
division    of,    from    liver,    re- 
sults of,  200 
splenic    extract    injections,    ef- 
fect of,  on,  198 
-cells,  red,  after  splenectomy  in 
dogs    (see  also  ery- 
throcytes), 12 
increased        resistance 
of,  196 
white,   after   wplenectomy    in 
dogs,  17 
differential   count,    19 
changes,  after  Eck  fistula,  127 
ligation  of  splenic  vein,   125 


INDEX 


40S 


Blood  chanjfps.  transplantition  of 
inferior  mesenteric  vein, 
128 
splenie   \(in   to   vena  cava, 
126 
in  man  after  sj)Ieneetomy,  SI 
crisis,    196.   278,  27!»,  291.,  321 

post-operative,  .S2,5 
examinations,       in       pernicious 
anttinia     before     and     after 
splenectomy,  221 
fat.  influence  of  splenec*'^"iv  on, 

84 
formation,    spleen,    absence    of. 
unessential  to,   198 
power  of,  in,  88 
splenic  extract,   influence   of, 
on,  98 
experimental  tests,  91 

technique,  9t 
increase   of   htemoglo- 

bin  content,  97 
leucocytes,  96 
red  cell  count,  97 
platelets,     increase     of,      after 

splenectomy,  279 
serum,     auto-agglutination     of, 
280 
changes  in,  in  splenic  disease, 

280 
hamolvtic  power  of,  test  of. 
280 
autolysis,  280 
heterolysis,   280 
isolysis,  280 
technique,   280 
transfusion,  291 

and  splenectomy,  347 

comparative  results,  294 
in  anaemia,  effects  of,  29* 


Hlood    transfusion,    i..    pernicious 
an»niia,  .SJ8 
haemolysis    and   agglutination 
tests,    I.indeman's    nietho<l, 
291 
Miiiot's  method,  29S 
selection  of  donor,  291,  349 
where  indicated,   294 
Bone    marrow,   changes    in,    after 
splenectomy,  140,  147, 
200 
after     varying     periods, 

148 
experimental       methods, 
142 
conclusions,    162 
results,  144 
histological    findings    in 
six  cases,  150 
discussion,   150 
hyperplasia,   150,   159 
compensatory,         1 43, 
159,  163 
in  femur,   143 
iron  storage,  I60 
literature,  discussion  of, 

140 
stimulation  theory,  325 
removal   of  normal   organ, 
141,  162 
haemoglobin  liberated  in,  67 
iron  content,  I60 
normal,  of  femur  of  dog,  145 

blood-cells  of,  146 
stimulating  effect  of  normal 
spleen  on,  111 
splenic     extract     injec- 
tions on,  198 
activity,     evidences      of,      in 
splenic  disease,  27,'. 


f 


* 


404 


INDEX 


i1 


O 


i) 

i 

2 


Bone    marrow    activity,    evidences 
oi  in  blood  plate- 
lets    and     leueo- 
cytes,  -297 
evidences  of  by  fixed 
smear'-,  277 
polychro- 
matophilia,  27!) 
by     vital     staining, 
'  275 
Botlaz  zi'i      liKmocatatonistic 

theory,  8!) 
Bronchitis    complicating    splenec- 
tomy, 257 

Choli   '     -■",  influence  of  splenec- 
tomy on,  81 
Cirrhosis  of  liver,  splenectomy  in, 

305 
Cobra  venom  test  for  ht  n»olysis, 

50 
Congenital  hwmolytic  jau;idice, 
metabolism 
studies  D  e  f  o  r  e 
and  after  splen- 
ectomy, ammonia 
nitrogen,  215 
creatin       excretion, 

215 
fats.  217 

hydrogen    ion    con- 
centration, 215 
iron        elimination, 

217 
nitrogen,  211 
uric     acid     output, 

211. 
urobilin  elimination, 

218 
protein,  2.'»4 


Control  experiments  for  diversion 
of  splenic  bWa  from  'iver  with- 
out splenectomy,  121 

Creatin  excretion  in  congenital 
haemolytic  jaundice,  before  anu 
after  splenectomy,  215 

Crisis  of  deglobuliz^ition,  314,  329 

Cysts  of  spleen,  343 

Diet,  influence  of,  on  anaemia  afte/ 

splenectomy,  22,  19ti 
normal  adequacy  of,  for  jplen- 

ectomized  dog,  29 
Dislocated  spleen,  341 

Eck  fisti.la,  experimental  method, 
123 
blood    changes     following, 
127 
conclusions,  129 
efTect    of,     on     action    of 

haemolytic  agents,  130 
jaundice,  lessened  tendency 

to,  after,  138 
splenic  blood  diverted  from 
liver  by,  200 
Emotion,  efl"ect  of,  on  bicod  count 

after  splenectomy,  14 
Eosinophilia,  after  splenectomy  in 

dogs,  18 
Erythraemia     (see     Poljeythaemia 

rubra),  302 
EryUirocytes,   Cabot   ring    forms, 
278 
resistance  of,  to  haemolytic  serum 
injections,  109 
hypotonic    salt    solution,    67, 
271 
test  of.  272 
to  saponin,  271 


INDEX 


405 


Erythrocites,    reticulated   or 
skeined,  275 
in  disease,  276 
in  hEeniolytic  jaundice,  276 
in     normal    liuman    blood, 

276 
i;ature  of,  277 
vital  staining  test,  275 
Fwces,  analysis  of,  for  iron.   115 
Fat     metabolism     in     relation     to 

splenectomy,  190 
Fats  in  congenital  liapmolytic  jaun- 
dice  before  and  after  splenec- 
tomy, 2 1 7 
Fatty  acids  and  lipoids,  influence 

of,  in  haemolysis,  83 
Fertility    of    animals,    effect    of 
splenctomy  on,  5 

Gaucher's  disease,  2Ja 
acute,  2 '6 
bone-mairow.    power    of,    in 

blood    regeneration,    2i7 
etiology,  246 
pathology,  245 
prognosis,  247 
symptomatology,  246 
blood  changes,  247 
enlargement  of  liver,  247 

spleen,  246 
skin,  247 
splenectomy,  247,  311,  344 
Glenard's  disease,  341 

Hsemocatatonistic  tlie  r     of   Bot- 

tazzi,  89 
Hiemoglobin,  chiuigt  ^  to  bile-pig- 
ment, 63 
course    of,    liberated    in    bone- 
marrow,  67 


Haemoglobin,   course   of,  to   liv 
before     and     after     splenec- 
tomy,  197 
degree  of  retention  necessary  to 

cause  jaundice,  59 
estimations  in  dogs,  after  splen- 
ectomy, 14 
free  in  blood  of  splenic  vein,  89 
in    splenic    blood-serum,    89, 
92 
test  for,  go 
results,  92 
removal  of,  from  blood-serum, 

mechanism  of,  62 
saturation  point  of  liver  for, 
65,  74 
increased    after    injections    of 

splenic  extract,  97 
in  j  ections  of ,  into  portal  and  gen- 
eral circulation,  68 
persistence    of    jaun- 
dice after,  70 
results  of,  69 
percentages    of,    eliminated    by 
kidneys,  59 
in     spIenectomiKcd     ani- 
mals, 6S 
rate  of  injection  a  factor  in  tol- 
eration by  liver,  66 
removed  by  liver,  63 
tests  for,  after  splenectomy,  54 
HainoglobinfEmia   in   normal   ani- 
mals, 59 
Hwmoglobinuria,  influenced  by  site 
of    hemoglobin    injections, 
70 
in  normal  animals,  degree  of, 
necessary  for  escape  of 
haemoglobin  through  kid- 
neys, 59 


mm 


406 


INDEX 


i' 


U 


.'1 


u 


Hemoglobinuria    in    normal    ani- 
mals, methods  of  in- 
vestigation, of) 
results  of,  (50 
lessened  tendency  after  splenee- 
tomy    and    use   of   huemolytic 
agents,  S  ^,  1<)7 
Haeniolyniph  nodes  after  splenec- 
tomy, 168.  177 
Ileterolysins,  280 
Hemolysins   in    biood  serum,   280 
Hemolysis,  fatty  aeids  and  lipoids, 
influence  of,   in,   8.'i 
literature    on    subject, 
83 
salt  solution  test,  \0 
hypotonic,    1-2 
spleen,  absence  of,  not  essential 
to,  195 
influence  of,  in,  .'3P,  72 
Hsemolytic    agents,    resistance    to, 
after  Eck  fistula,  130 
ligatien     of    splenic     vein, 

130 
transplantation   of   splenic 
vein,  130 
immune  serum  test,    15 
jaundice,  2.")l 

action  of  liver  on  free  hemo- 
globin, 26t 
acute  malignant,  257 
atypical  cases,  260 

absence  of  jaundice,  261 
auto-agglutination    test,    256, 

258 
blood  coimt  in,  258 
cfl^'ect  of  splenectomy  on,  26 !• 
findings  at  autopsy,  265 
cardinal  symptoms,  257 


Hemolytic     jaundice,     congenital 

(see     also     Congenital 

hemolytic  jaundice), 256 

red-blood  cell  resistance  to 

hypotonic    salt    solution, 

256 

crisis  of  deglobulization,  329 

differentiation    of    congenital 

and  acquired.  257,  280 
familial,  258 
identity  of  types,  260 
increase  of  microcytes  and  re- 
ticulated red  cells,  256 
pathogenesis,    263 

source   of    increased   blood 

destruction  in,  26l 

red  cell  resistance  decreased, 

due    to    indirect    injury    to 

bone-marrow,  261 

simulating  pernicious  anemia, 

261 
splenectomy  in,  259,  311' 

results  of,  330 
symj)tomatology,  25J 
blood  changes,  255 
splenic  enlargement.  255 
treatment  of,  by  splenectomy. 
312,  316 
results  of,  313 
surgery    of    bile-passages, 
297" 
j)ower  of  extracts  of  spleen,  78 
and  other  organs,  82 
experiments,    'esultj   of, 
82 
technique  of,  81 
literature  on  subject,  79 
resistance  increased  by  anfemia, 
50 


INDEX 


407 


Htemolytic    serum,    effect    of,    on 
anemia      in      uasplenec- 
toniized  dog,  71 
splentctoraizcd     dogs,     55, 
10'^ 
with  normal  blood,  75 
injections,  jaundice  producfd 
by,  1.3  J 
leucocj'tes  and  differential 

blood  counts  after,  108 
leucocytosis    produced    bv. 

138 
recovery  from,  in  splentc- 

tomized  dog,   103 
resistance  of  red  blood-cells 
after,  109 
metabolism,    changes     in, 
caused  by,  i234 
splenomegaly,  26'2 
degenerative,  26a 
regenerative,  262 
Ha-mopsouiics,    change    in,    after 

splenectomy,  175 
Httmorrhagic  anwmia  in  splenec- 
tomized  dog,  blood  repair  after, 
7 
Hodgkin's  disease,  2H 
Howell-Jolly  Iwdies.  278 
Hydrogen  ion  concentration  in  con- 
genital  hemolytic  jaundice  be- 
fore and  after  splenectomy,  215 
'^ype^plasia  of  lymph-nodes  after 

splenectomy,  1 69 
Hypersplenism,  265 
Hypotinie  salt  solution,  resistance 
of    erythrocj'tes    to,    67, 
271 
tests,  42 


Icterus   (see  Jaundice), 
alcoholic,  255 
lessened      tendency     to,      after 

splenectomy,  5-i 
pleiochromie,  264 
Intoxication,  acute,  after  feeding 
splenectomized      animals      with 
sheep  spleen,  99 
Iron  conservation  by  the  organism, 
113 
elimination   of,   from   the   body 
before   and   after   splenix;- 
tomy,  113,  116 
in  congenital  hemolytic  jaun- 
dice before  and  after  splen- 
ectomy, 217 
in  health  and  anemia,  236 
in   pernicious   anemia  before 
and  aftei  splenectomy,  224 
in  relation  to  spleen,  230 
in  splenectomized  and  normal 
dogs,  1 1 1 
analysis  of  feces,  1 1 5 
experiments,  1 1 4 
ferrous         sulphate 

feeding,  120 
food   used   in,    ll6 
results,  116 
increased,  after  splenectomy, 
due  to  anemia,  1 19 
increased  hemolysis,  MQ 
not  dependent  directly  on 
absei.ce  of  spleen,  199 
exchange  of,  influence  of  splen- 
ectomy on, 235 
indirect    effect    of.    in    experi- 
nuntal  splenectomy,  26 


408 


INDEX 


U 


Iron,     microchcmical     tests     for, 
aftei-   splenectomy,   in 
liver,   177 
in  ljmi>li-nodes,  177 
content  of  bone-marrow,  l60 
metabolism    after    splenectomy, 
191 
influence  of  spleen  on,  112 
storage    by    bone-marrow    after 
splenectomy,  l60 
Iso-agglutination  of  blood-serum, 

280 
Isolysius,  280 
von  Jaksch's  disease,  241,  251 

treatment  of,  by  splenectomy, 
314,  344 

Jaundice      after      splenectomy, 
ansmia  a  factor,  73 
influence  of  iiicieased  red-cell 
resistance  on,  77 
htemolytic  agents,  197 
chronic  family,  254 
htemolytic,  254 

congenital     (see     Congenital 
haemolytic         jaundice), 
202 
metal)olisni,  227 
influence  of  ana'mia  on,  72 
in  hrmolytic  serum  experiments, 

133 
lessened     tendency     to,     after 
splenectomy,  72 
persistence  of,  77 
vein   ligation   and   blood 
vess°I  anasto  nosis,  72 
produced    by    tohiyicnediaminc 
experiments,  131 

Kupffcr's  cells,  176 


Leucocyte  count  after  splenectomy 

in  dogs,  1 7 
Leucocytosis,       after      heemolytic 
serum  injections  and  splen- 
ectomy, 108 
haemolytic  agents,  1S8 
I^'uka-mia,     splenectomy     contra- 
indicated,  10,  300,  301 
I.indeman's  test  for  ha-molysis  and 
agglutination    in    blood    trans- 
fusion, 291 
Liver,  changes  of,  after  splenec- 
tomy, 164 
and  injection  of  haemolytic 
serum,  176 
phagocyt  sis,  176 
blood  destruction,  169 
iron,    presence    of,    micro- 
chemical     bests 
for,  177 
histologic  results, 
178 
compensatory      function      after 

splenectomy,  180 
diversion  of  splenic  blood  from, 

without  splenectomy,  121 
saturation   point  of,  for  haemo- 
globin, 65,  74 

Lymph-nodes,    changes    in,    after 

splenectomy,  164,  201 

and  injections  of  haemo- 

Ij'tic  serum,  172 
blood  destruction,  l69 
discoloration,  l68 
endothelial  cells,  prolif- 
eration of,  171,  173 
histological,  170 
hyperplasia,  167,   169 


INDEX 


409 


L3rmph-nodes,     changes    in    iron, 

niicrochemical    tests 

for  presence  of,  177 

histological    results, 

178 

literature,         discussion, 

15-1 
new  formation,   167 
phagocytosis,  169,  173 
course  of,  175 
time  relation  of,  173 
red-cell  formation,  l67 
compensatory  formation  after 

spleneciJiuy,  180 
in      congenital      absence     of 

spleen,  166 
haemo-,  168,  177 
Lymphocytosis  following  splenec- 
tomy in  dogs,  18 

Malaria,  splenectomy  in,  307 
Malarial  spleen,  339 
Merck's  Saponin  Purum,  49 
Mesenteric    vein,    inferior    trans- 
plantation   of,    blood    changes 
after,  128 
Metabolism  in  man  after  splenec- 
tomy, literature  on,  226 
of  normal  organ,  literature, 

229 
iron  cxchanfTp.  235 
before  and  after  splenectomy, 
literature,  225 
urobilin  output,  235 
studies  of,  202 

Banti's  disease,  225 
haemolytic  jaundice,  202 
history  ot  case,  203 
family,  204 
laboratory  examina- 
tions, 201 


Metabolism    in    man,    laboratory 
examina- 
tions,    methods 
of  study,  209 
blood,  206 
diet,  210 
faeces,  211 
urine,  2 1 1 
operation  of  splen- 
ectomy, 207 
diagnosis,  209 
microscopic      ap- 
pearance      o  f 
spleen,  209 
pathologic      d  e  - 
scription,  208 
symptoms,  203 

a  t     beginning     o  f 

studies,  205 
results  of,  211 
ammonia       nitro- 
gen, 215 
creatinin        and 

creatin,  215 
fats,  217 
hydrogen  ion  con- 
centration, 215 
iron    elimination, 

217 
nitrogen  balance, 

211 
summary  of,  219 
uric   acid   output, 

214 
urobilin    elimina- 
tion, 218 
of     pernicious     anemia, 
220 
clinical  notes,  223 


410 


INDEX 


J' 


Metabolism    in     man,     pernicious 
ananuia,      results, 

iron      elimination, 

nitroijen        balance, 

uric    acid    elimina- 
tion, urobilin,  22  V 
summary  of,  221' 
in     relation     to     spleen, 

ansemia,  '^28 
changes  caused  by  ha-nio- 
lytic  serum,  2.'?4 
Metabolism  in  man  in  relation  to 
spleen,    congenital 
ha'molytic       jaundice, 
227 
iron  elimination,  230 
nitrogen  balance,  231 
protein  destruction,  232 
uric  acid  elimination,  232 
in  relation  to  s))lenectomv,  ex- 
perimental    studies, 
181 
blood        examinations, 

191 
body   weiglit  increase, 

193 
creatin    excretion    ab- 
sent, 187 
increased,  '89 
discussion  of  observa- 
tions, 191 
earlier  investigations.  181 
faeces,     examination 
of,  181. 
fat,  181. 

fat      determina- 
tions, '90 


Metabolism  in  relation  to  splenec- 
tomy, experi- 
mental studies, 
greater  food  re- 
quirement, 193 
influence  of 
an»mia  o  n  , 
187,  193,  194 
iron    elimination, 

191 
methods,  183 
nitrogen  determi- 
nations, 181 
results  of,   \S\ 
summary,  19  ^ 
urine,  analysis  of, 
184 
literature,  229 
iron,  influence  of  spleen  on.  112 
experimental  results.  118 
process  of,  1 1 2 
nitrogen,    in    congenital    jisemo- 
lytic     jaundice     before     and 
after  splenectomy,  211 
not  aff'ected  by  splenectomy,  201 
Minot's  test  for  haemolysis  and  ag- 
glutination in  blood  transfusion, 
291 

Nephrectomy,  a  control  operation 

for  splenectomy  in  dogs,  29 
Nitrogen    metabolism    in    anaemia, 
literature,  231 
pernicious  anaemia  before  and 

after  splenectomy.  223 
in    relation    to    splenectomy. 
181,  18i 

Pernicious  anaemia,  26,'> 

blood  examinations  in  case  of. 
before  and  after  splen- 
ectomy, 221 
transfusion  in,  348 


INDEX 


411 


I 


Pernicious    aiuemia,    hypersplen- 
ism,  265 
iron    elimination    in   case    of, 
before   and   after   splenec- 
tomy, 2^t 
metabolism  study  in  case  of, 
before   and   after   splenec- 
tomy, 2i2() 
nitrogen   balance   in  case  of, 
before   and   after   splenec- 
tomy, 2 '2  3 
pathogenesis  of,  265 

Eppinger's  theory,  2()7 
remission    of,    after   splenec- 
tomy, 320 
splenectomy  in,  265,  34i 
effect  on  metabolism,  clini- 
cal notes,  223 
iron,  222 
uric  acidj  222 
urobilin,  222 
treatment  of,  by  blood  trans- 
fusion, 294 
and  splenectomy,  295 
splenectomy,  31-t 

analysis  of  results,   318 

influence  of  age,  322 

degree  of  ansmia, 

324 
sex,  323 

size    o  f    spleen, 
824. 
blood  changes,  321 
crisis  after,  321 
centra-indications,  327 
aplastic   bone-marrow, 

327,  329 
spinal     cord     symp- 
toms, 327,  329 
effect  produced  by,  324 
blood   crisis,   325 


Pernicious    anaemia,   treatment   of 
splenectomy,    ef- 
fect produced  by 
bone-m  arrow 
stimulation,   325 
erythrocytes,       i  n  - 
creased         resist- 
ance of,  326 
indications  for,  327 
mortality,  321 
percentage  of  cures,  321 
results  of,  317 
summary  of,  328 
time  for  operation,  329 
value  of,  315 
splenic    extract    injections, 

329 
surgical  removal  of  chronic 
sources  of  infection,  298 
uric  acid  elimination  in  case 
of,  before  and  after  splen- 
ectomy, 224 
urobilin    elimination    in    case 
of,  before  and  after  splen- 
ectomy, 224 
Phagocytosis,    increase    of,    after 
splenectomy    and    injection    of 
hamolytic  serum,  171,  176 
Pheiochromic  icterus,  264 
Pneumonia   complicating   splenec- 
tomy, 357 
Poikilocytosis  after  splenectomy  in 

dogs,  16 
Polychromatophilia,  279 

after  splenectomy  in  dogs,  I6 
Polycythaemia  rubra,  302 
etiology,  304 
haemolysis  in,  303 
symptoms,  303 
treatment,  304 

splenectomy       contra  indi- 
cated, .304 
X-ray,  305 


iU 


INDEX 


1 

\'^>';^^M 

1 J 

«'■' 

-^'t^^^^^l 

'''^^^^^^^1 

^i^^H 

y 
^ 

^x-.^^^i 

^'-.  ^^^H 

c 

yjd^H 

-^^^H 

^ 

1. 

^^^^^^1 

■■[^^^^H 

N 

^^^^^^1 

< 

^^^^^1 

< 

Polyglobulia,  314 
Protein  metabolism,  233 
Pseudo-Banti's  disease,  252 
Pseudoleiikficmia,     "  splenic    vari- 
ety," 241 

Racliitischc  mejjalosplcine,  254 
Iltd  blood-cells  increased  after  in- 
jections   of    splenic    ex- 
tract, 97 
resistance  of,   after  baemo- 
lytic  serum  injections, 
109 
sodium     oleate     antemia, 

110 
in    relation    to    splenec- 
tomy, 38 
test    by     beemolytic 
immune  serum, 
45 
hypotonic  salt  so- 
lution,  42 
saponin,  47 
increased  after  splenec- 
tomy, 38 
cauise  of.  50 
conclusions 

of  author,  52 
influence    on    jaun- 
dice. 77 
to     cobra     venom     after 

splenectomy,  50 
to  httmo lytic  agents,  in 
wounds  and  splenec- 
tomized  dogs,  199 
t  o  hsemolytic  agents, 
summary  of  observa- 
tions in  normal  and 
splenectomized  a  n  i  - 
mals,  110 


Ripper  and  Schwarzer  method, 
modified,  of  analysis  of  fwces 
for  iron,  1 15 

Rupture  of  spleen,  334 

Salt  solution  test  for  htemolysis,  40 
Saponin,  resistance  of  erythrocytes 

to,  271 
Saponin  test,  47 

Sodium  oleate  anasmia  in  splenec- 
tomized animal,  105 
.Spleen  a  factor  in  hsemolysis,  72 
absence  of,  a  factor  in  chronicity 
of  antemia  and  slow  re- 
pair, 105 
slow  repair  of  sodium  oleate 
aneemia,  106 
congenital,  8 

correlation   of   increased   red 
'    cell    resistance    and    de- 
creased   jaundice    after 
haemolytic  poisons,  1 1 1 
essential    factor    in    ansmia, 

196 
influence  on  haemoglobin  and 
jaundice,  59 
nitrogen  metabolism,  187 
unessential    to    blood    foi-ma- 
tion,  198 
Iisemolysis,  198 
arterial    and    venous    blood    of, 
comparison  of,  87 
difl'"erential  counts,  91 
reticulated  or  skeined 

red  corpuscles,  93 
total  ha-i'ioglobin,  91 
changes    in,    after    ligation    of 

splenic  vein,  1  '  I 
dislocated,  in  mnn^  Sil 


INDEX 


413 


Spleen,  effect  of,  on  bone-marrow, 
111 
hsemopoietic  system,  98 
red   cell    formation    in    bone- 
marrow,  97 
enlargement  of,  211 

in  Gaucher's  disease,  2 IG 
experimental  studies  in  animals, 
11 

extirpation     of     (see     Splenec- 
tomy), 3 
anatomical    considera- 

tions,  345 
history  of,  in  animal,  3 
in  hmnan  beings,  6 
feeding    of,    to    splenectonii^ed 
dogs,  97 
influence  of,  98 
method,  98 
results,  98 
haemolytic  function  o.',  326 
on  haemolysis,  39 
iron  metabolism,  12 

experimental  results,  118 
regulatory,  on  blood,  58 
blood   destruction   and   re- 
generation, 87 
early   literature,  87 
in    relation    to 
ancemia,  87 
in  Banti's  disease,  causative  re- 
lationship of,  253 
in  hasmolytic  jaundice,  255 
in  relation  to  blood  supply  of 
liver,  64 

hemoglobinuria  and  jaundice, 
58 

haemopsonins,  175 


Spleen,  in  relation  to  metabolism, 
29 
in  man,  literature  on  sub- 
ject    (see     Metabolism), 
225 
lesions  of  surgical  treatment  of, 
333 
abscess,  337 

operative       mortality, 

339 
splenectomy,  338 
splenotomy,  338 
cysts,  non-parasitic,  34S 

parasitic,  313 
gunshot      and      stab 

wounds,  333 
malarial  spleen,  339 
rupture,  334 
mortality,  336 
prognosis,  336 
splenomegaly,  344 
syphilis  of  spleen,  341 
tuberculous  spleen,  340 
tumors,  343 
wandering  spleen,  341 
not  essential  to  life,  8 
regeneration   of,   after  extripa- 

tion,  6 
simple  hypertrophy  of,  242 
site    of   disintegration    of    ery- 
throcytes, 66 
spodogenoHs,  65 
trauma  of,  cause  of  Banti's  dis- 
ease, 251 
venous  blood  of,  more  resistant 
than  arterial,  litera- 
ture reports,  89 
negative  findings,  91 
wandering,  ligation  of  arterv  in, 
297 


414 


INDEX 


I'; 


(.,. 


Spleen,  X-ray  trratment,  in  splt-nic 

diseases,  2<)fi 
Spleens,  accessory,  in  dog,  21 
Splenectomized  animals  more  re- 
sistant to  lueinolytic  poisons,  38 
Splenectomy  and  anieniia,  relation 
of     e  X  p  e  r  i  - 
mental  studies, 
general       sum- 
mary, 195 
the  anaemia,  \<)5 
blood  crisis,  igs 
diet,  influence  of, 
196 
Splenectomy,  in  dogs,  1 1 

accessory    spleens,    influence 

of,  21" 
antemia    following,    12,    Hi, 
158 
factor  in  jaundice.  73 
artificially  produced, 

sunmiary    of   observa- 
tions, 1 10 
blood  count  emotion,  ef- 
fect of,  on,  M 
cosinophiles,  18 
erythrocytes,  13 
skeined  or  reticu- 
lated, 16 
haemoglobin  content, 

J  3 
lymphocytosis,  18 
myelocytes,  20 
poikiloeytosis.   1(5 
polvchromatophilia, 

16 
red  cells,  13 
white  cells,  17 
character  of.  15 


Splenectomy  in  dogs,  anamia  fol- 
lowing   diet,    in- 
fluence of,  on,  22, 
24,  30,  34 
food,     raw      and 

cooked,  31 
iron,  26 

iron-rich  food,  23 
experimental    c  o  n  e  1  u  - 

sions,  .^3 
progressive  onset  of,   12 
•tage    of    beginning    re- 
pair, 16 
bile-pigment,     changes     i  n , 

after,  (]S 
bile  test,  after,  5't 
blood  changes  variable  after, 

26 
blood   su})ply  of  liver   ;  fter, 

197 
bone-marrow     condition      of, 

after,   147 
cholcsterin  increase  of,  after, 

84 
controlled    by     previous    ne- 
phrectomy, 29 
eff"ects  of,  5 

mortality,  6 
first  authentic   operations   on 

dogs.  4 
hwniojilobin  estimation   after, 

n 

lia;nioglobinuria,     after,     test 

for,  54 

and    jaundice,    dec  Tased 

tendency    of,   after,    54, 

197 

heemopsonins,     change      i  n , 

after,  175 
history  of,  3 


INDEX 


415 


Splenectomy,  iron  pliininition   be- 
fore and  after,   116 
experimental      results, 

118 
increase  of,  after,  due 
to  anu>iiiia,  1 19 
lessened  tendency  after,  31 
liver     changes     after     (  s  c  e 

Liver),  Kil,  176 
lymph-nodf      changes      after 

(see  Lymph-nodes),  Kil. 
nature  of  function  lost  after, 

lai 
in  relation  to  fatty  acids  and 

cholcsterin  content,  198 
red    cells,    resistance    of,    to 
hemolytic        agents 
after,    summary    of 
observations,   110 
increased     after,     38, 
196 
cause,  196 
test  by  salt  solution, 
40 
shaking,  41 
resistance    to    blood    poisons, 
after,  11 

influence  of,  on  blood,  1 1 
blood  fat,  84 

on  bone-marrow  (see  Bone- 
marrow),  110,  200 
cholcsterin,  84 
on  fertility,  5 
general  nutrition,  25 
lymph-nodes,  201. 
metabolism    (see    Metabol- 
ism), 23,  181 
on  resistance  of  red  blood- 
cells,  39 


Splenectomy,    resistance    of     red 
bl.)od    cells    to 
hemolytic     im- 
mune      serum, 
45,   109 
to  hypotonic  salt  so- 
lution, 43 
to  saponin,  47 
on  weight,  23 
without  influence  on  metabol- 
ism, 201 
Sjilenectomy    in    various    animnls^ 
antemia  after,  22 
autopsy  findings,  6 
Splenectomy  in  man,  202 

anwmia,  delayed  repair  of,  in 
absence  of  spleen,  i'jG 
duration  of,  after,  37 
anatomical  considerations,  345 
and  blood-transfusion,  347 
comparative  results,  294 
blood  changes  after,  34 
reported  cases,  35 
blood  platelets  increased  after, 
879 
supply  of  portal  vein  lessened 
after,  198 
choice  of  time  for  operation,  329 
complications,    of    hemorrhage, 
856 
injuries  to  adjacent  viscera, 
357 
contra-indications,  291,  300 
hemorrhagic  diathesis,  300 
leukaemia,  10,  300,  301 
polycythaemia  rubra,  302 
severe  ansemias,  300 
first  recorded  operations,  6 
for  wandering  spleen,  342 
history  of,  6 


416 


INDEX 


SpUncctomy,    functional    cquilib- 
riuiii  after,  'i'.i  i 
abscess  of  spleen,  338 
ill   B'lnti's  disease,  341 
in  cirrhosis  of  liver,  300 
ejsts  of  spleen,  313 
in  CJaucher's  disease,  '2  IT,  ^^^ 
in  ha-inolytic  jaundice,  3H 
in  V.  .laksch's  disease,  3  it 
in  niaiarial  spleen,  33J) 
in   pernicious   anieniia,  3li 
contra-indications,  327 
curative  action  denied,  32t) 
indications  for,   327 
summary  of  results,  328 
in  rupture  of  spleen,  336 
in  splenic   disease,  blood  crisis 

following,   278 
splenomegaly,  3H 
in  syphiliP  of  spleen,  341 
in  tuberculous  spleen,  3tO 
in  tumors  of  spleen,  3i3 
in  various  blood  diseases,  mor- 
tality, 309 
influence  of,  34 
on    metabolism   in   pernicious 

anaemia,  222 
on  urobilin  excretion,  287 
iron  elimination  after,  230 
metabolism   studies    before   and 
after      (see     Metabolism), 
202 
mortality,  10.  358 
operative  risks,  358 
positive  indic.itions,  309 

in  Banti's  disease,  309 
Gaucher's  disease,  311 
hnemolytic  jaundice,  312 
V.   Jaksch's  disease,  314 
pernicious  antemia,  814 


Splenectomy,  possible  indications, 
305 
cirrhosis  of  liver,  305 
inalatia,  307 
syphilis,  308 
sequela'  of,  357 
bronchitis,  357 
pneimioiiia,  357 
technique.  350 

closure  of  splenic  space,  355 
control  of  hemorrhage,  352 
ligation  of  pedicle,  353 
removal  of  organ,  351 
value  of,  as  a  therapeutic  pr«>- 
cedure,  '299 
Splenic  blood,  diversion  of,  from 
liverbyKck  fistula,  121 
by    ligation    of    splenic 

vein,  121 
by     transplantation     of 

splenic  vein,  121 
without  splenectomy,  121 
blood  crisis  following  splen- 
ectomy, '278 
diagnostic     and     prognostic 
methcds,  269 
agglutinins  and  hsemo- 
I  y  s  i  n  s    in   blood- 
serum,  280 
blood  examinations, 

270 

bone-marrow    activity, 

evidences  of,  275 

blood        platelets 

and  leucocytes, 

279 

by    fixed    smears, 

'277 
by  vital  staining, 
i7!i 


INDEX 


417 


Splenic    disease,    history    taking, 
269 
hypotonic     -  It     solu- 
tion,    ;i 
ttciinique,  272 
laborntory  tests,  270 
physical    examination, 

269 
polychroma- 

tophilia,  279 
protein,  uric-acid,  and 
iron     metabolism, 
289 
red    blood-cell    resist- 
ance, 271 
urobilin  excretion,  281 
urobilinogen  excretion, 

281 
vital  staining,  275 
treatment  of,  291 

blood     transfusion      (see 

Blood  tr(»nsfusion),  291 

medicinal      and      hygienic 

measures,  296 
•urgical,  297 

cauterization     and     d  e  - 
struction     of     spleen, 
297 
ligation  of  blood-vessels 

of  spleen,  297 
Schiazzi's      "  splenoclei- 
sis,"  297 
extracts,  heeniolytic  power  of,  78 
experiments,    results    of, 
82 
technique  of.  81 
literature  on  subject,  79 
influence  of,  on  blood  forma- 
tion, 98 
V 


Splenic  extract,  influence  of,  ex- 
perinient- 
al  ttst,  94 
results,  g5 
technique,  94 
leucocytes  increased, 
96 
injections  of,  in  anaemia,  94 
stimulating  action  on  blood, 

198 
on  bone-marrow,  19ft 
vein,  ligation  of,  121 

circulation     after     adjust- 
ment of.  125 
blood    changes    after,  125, 

200 
hasmolytic  agents,  action  of, 

after,   130 
jaundice,  lessened  tendency 

to,  after,   138 
method  of  experiment,  128 
spleen,  changes  in,  124 
transplantation  of,  into  vena 
cava,  121 
blood  changes  follow- 
ing, 126 
hiemolytic    agents, 
action  of,  after,  130 
jaundice,  lessened  ten- 
dency to,  after,  138 
method  of  experiment, 
123 
Splenocleisis,  297 
Splenomegaly,  344 
heemolytic,  262 
"  idiopathic,"  242 
large-celled  (see  Gaucher 's  dis- 
ease), 243 
produced  by  subci'taneous  injec- 
tions of  Bacillus  coli,  230 
with  anemia,  241 


418 


INDEX 


Splenomegal}-,    classification    and 
types,  2H 

hepatic    cirrliosis    (see    Banti"- 
disease),  '21-8 
Splenopexy  in   wandering  spleen, 

342 
Splenotomy,  in  abscess  of  spleen, 

338 
Syphilis  of  spleen,  341 

splenectomy  in,  307 

Test,  auto-agglutination  in  htemo- 
lytic  jaundice,  256,  258 
for    auto-agglutinins    in    blood- 
serums,  t.'8() 
technique,  280 
for  bile  after  spltncetomy,  54 
for  effect  of  s|)leen  feeding  to 

spleneetoini/.ed  dogs,  98 
for  free  liaemoglobin  in  splenic 

blood-serum,  90 
for  hemoglobinuria  after  splen- 
ectomy, 54 
for    haemolysis    and    agglutina- 
tion in  blood  transfusion,  291 
for  haemoiytic  power  of  blood- 
serum,  280 
splenic  extracts,  81 
resistance  of  erythrocytes  by 
cobra  venom,  50 
for  influence  of  splenic  extract 

on  blood  formation,  94 
for  iron  metabolism  in  aplenec- 
Lomized      and     normal 
dogs,  1 14 
with  saponin,  47,  271 
for    urobilin    excretion,   Wilbur 
and  Addis  method 
in  stools,  284 
in  urine,  282 


I   Test,  heemolytic  serum,  133 

I        microcheinical,  for  iron  in  liver 

after  splenectomy,  177 
!  lymph-nodes    after    splen- 

I  ectomy,  177 

I        toluylenediamine    for   jaundice, 
I  131 

leucocytosis  caused  by,  138 
of,     resistance     of     corpuscles, 
with    heemolytic    immune 
serum,  'i5 
with    hypotonic    salt    solu- 
tion, 42 
technique,  272 
vital  staining,  275 
technique,  275 
Transfusion  of  blood,  347 
in  splenic  disease,  2pl 
Tuberculosis  of  spleen,  340 
Tumors  of  spleer    343 

Uric  acid  elimination  before  and 

after    splenectomy    in 

congenital     haemoiytic 

jaundice,  214,  23S 

in     pernicious     anaemia^ 

224 
in   relation   to  spleen  in 
anaemia,  232 
Urobilin  elimination  after  splenec- 
tomy, 287 
in  anaemia,  287 
in  haemoiytic  jaundice,  287 
congenital,    before    and 
after  splenectomy,  218 
in  pernicious  r-   -pinia,  before 
and  after  splenectomy,  224 
in    relation    to    splenectomy, 

235 
in  splenic  disease,  281 


INDEX 


419 


Urobilin  excretion,  normal.  '2S7 

quantitative     estimation     of,     in 

duodenal    contents, 

Schneider's  metJiod,  288 

in  stools,  Wilbur  and  Addis 

method,  284 
in  urine,  Wilbur  and  Addis 
method,  282 
Urobilinogen  elimination,  281 
quantitative  estimate  of,  in  duo- 
denal    contents,     Schneider's 
method,  288 

Vaquez's    disease    (see    Polyeyth- 
aemia  rubra),  302 


Veins,  ligation  of  splenic,  121 
conclusions,  129 
transplantation      o  f ,      inferior 
mesenteric,    blood    changes 
after,  128 
portal   (Eck  fistula),  121 
splenic,  121 

conclusions,   129 
Vital  staining,  275 

Wandering  spleen,  .'JU 

White  blood-cells,  influence  on,  of 

splenectomy,  108 
Widal's    "crises    of    deglobuliza- 

tion,"  2,58 
'  Wounds  of  spleen,  3SS 


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